LIBRARY 

THE  UNIVERSITY 
OF  CALIFORNIA 

SANTA  BARBARA 


PRESENTED  BY 

DONALD  BEEKS 


MORPHINISM 


AND 


NARCOMANIAS  FROM  OTHER 
DRUGS 


Etiology,  Treatment,  and  Medicolegal 
Relations 


T.  D.  CROTHERS,  M.D. 

Superintendent  of  Walnut  Lodge  Hospital,  Hartford,  Conn.;    Editor  of  the 

Journal  of  Inebriety  ;  Professor  of  Mental  and  Nervous  Diseases, 

New  York  School  of  Clinical  Medicine,  etc. 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  &  COMPANY 
1902 


Copyright,  1902, 
By  W.  B  Saunders  &  Company 


PREFACE 


Historically,  opium  mania  is  a  very  old  dis- 
order. Morphinomania  is  the  modem  form  of  the 
same  disease,  and  the  various  drug  narcomanias 
which  are  associated  with  it  are  the  new  psycho- 
pathic forms  due  largely  to  modem  civilization.- 
There  can  be  no  question  that  these  diseases  are 
increasing,  as  they  are  certainly  becoming  more 
prominent  in  every  section  of  the  country.  Al- 
though morphinism  has  been  discussed  by  the 
profession  for  many  years,  the  literature  is  still 
limited  and  unsatisfactory.  A  few  volumes  written 
by  foreign  authors,  two  of  which  have  been  trans- 
lated into  English,  and  three  small  works,  some 
pamphlets  by  English  and  American  writers,  to- 
gether with  papers  in  medical  journals  and  brief 
notices  in  some  of  the  late  text-books,  comprise  all 
that  has  been  written  on  the  subject.  The  subject- 
matter  of  many  of  these  writings  consists  mainly  of 
minute  studies  of  different  methods  of  treatment, 
with  some  theories  and  descriptions  of  the  sympto- 
matology and  causes.  In  most  of  these  works  the 
impression  is  given  that  morphinism  is  a  mere  acci- 
dental and  incidental  neurosis  which  may  be  largely 
influenced  by  restrictive  legislation  against  narcotic 
drugs.  Every  year  the  increasing  prominence  of 
this  psychosis  calls  for  more  exact  studies,  with  a 

5 


6  Preface 

fuller  recognition  of  the  conditions  and  causes  of  the 
disease.  While  the  general  facts  of  disease  have  been 
recognized,  they  have  not  been  studied  to  any  great 
extent  or  from  a  broad  scientific  point  of  view. 

Medical  colleges  have  not  yet  introduced  this  study 
into  their  curriculums,  and  the  dangers  from  narcotic 
drugs  a.nd  other  narcomanias  are  practically  un- 
known to  the  recent  graduate. 

Medicolegally,  questions  of  responsibility  have 
been  asked  with  increasing  frequency,  and  there  is 
no  literature  and  no  study  of  the  subject  to  afford 
an  intelligent  answer.  The  special  object  of  this 
work  is  to  group  the  general  facts  and  outline  some 
of  the  causes  and  symptoms  common  to  most 
cases,  and  to  suggest  general  methods  of  treatment 
and  prevention,  and  in  this  way  try  to  bring  the  sub- 
ject out  from  its  present  empirical  stage  to  higher 
and  more  scientific  levels,  and  to  encourage  further 
and  more  exhaustive  studies. 

This  work  is  intended  to  give  a  general  preliminary 
survey  of  this  new  field  of  psychopathy,  and  to  point 
out  the  possibilities  from  a  larger  and  more  accurate 
knowledge,  and  so  indicate  degrees  of  curability 
which  are  at  present  unknown. 

The  great  practical  questions  which  appeal  to  the 
medical  profession  for  answers  may  be  stated  as 
follows : 

What  are  the  causes  and  conditions  which  de- 
velop morphinism  and  lead  to  other  narcomanias, 
and  how  can  they  be  recognized,  averted,  and  pre- 
vented? 

What  means  and  methods  are  essential  for  the 


Preface  7 

cure  in  the  early  stages,  and  how  can  they  be  suc- 
cessfully treated  in  the  later  and  chronic  condi- 
tions? What  can  be  done  with  the  growing  armies 
of  drug  neurotics  ?  How  can  we  care  for  them  and 
treat  them  practically? 

These  are  a  few  of  the  problems  for  the  solution  of 
which  this  work  is  offered  as  an  aid  and  guide. 

T.  D.  Crothers. 


NOTE  OF  ACKNOWLEDGMENT 


This  work  is  the  practical  summary  of  the  clin- 
ical experience  of  over  a  quarter  of  a  century  of 
active  treatment  and  care  of  narcomaniacs.  During 
this  period  a  great  variety  of  facts  and  notes  have 
been  gathered  from  papers  and  books  the  authors 
of  which  are  dead  or  forgotten,  making  it  almost 
impossible  to  trace  them  back  to  their  source. 
Hence  we  can  only  indicate  the  general  sources 
of  obligation,  and  this  is  done  as  a  tribute  of  re- 
spect for  the  pioneer  work  of  journals  and  authors. 
All  writers  must  acknowledge  the  great  value  of  the 
numerous  papers  and  clinical  notes  on  morphinism 
and  other  narcomanias  which  have  appeared  in  the 
pages  of  the  "Journal  of  Inebriety"  since  its  first 
publication  in  1S76.  Also  to  the  "Alienist  and 
Neurologist"  and  its  distinguished  editor,  Dr.  C.  H. 
Hughes,  and  his  personal  writing  on  this  subject, 
"^he  papers  of  the  late  Drs.  Kerr  of  London  and 
Parrish  of  this  country,  also  of  Drs.  Mattison,  Lett, 
Waugh,  Mason,  Mann,  Clevenger,  Wood,  Kellogg, 
Brown,  and  many  others,  have  given  very  helpful 
and  suggestive  studies  of  the  subject.  The  works 
of  Erlenmeyer,  Ball,  Levenstein,  and  others  have 
been  found  very  practical  and  suggestive.  The 
literature  written  for  popular  readers  often  contains 
many  clear  psychologic  descriptions  of  these  neu- 

9 


lo  Note  of  Acknowledgment 

roses,  yet  in  reality  is  untrustworthy.  Vivid  de- 
scriptions of  opium  and  morphin  manias  have  often 
profoundly  influenced  sensitive  persons,  and,  all  un- 
consciously, they  have  imitated  the  examples  read. 
Medical  writers  with  an  imaginative  turn  have  fol- 
lowed the  same  lines  in  their  descriptions  of  narco- 
manias. This  literature  has  no  scientific  value,  and 
is  of  only  psychologic  interest. 


CONTENTS 


CHAPTER  I  PACK 

The  History  of  Morphinism 17 

Early  History  of  Opium.  Its  Use  as  a  Sedative  and 
Narcotic.  Some  Theories  of  Its  Value.  The  First 
Book  on  This  Subject.  Later  Papers  and  Theories. 
Use  Externally  through  the  Skin.  Early  Use  of  the 
Syringe.  First  Use  of  Morphin.  Recognition  of  the 
Danger  of  Morphin  by  the  Needle.  Early  Writers 
and  Their  Views.  First  Classification.  Its  Preva- 
lence in  Europe  and  This  Coimtry.  Chemical  Proper- 
ties of  Morphin;  Classes  of  Persons  Using  It.  Use 
among  Physicians.  Difficulties  in  Determining  the 
Extent  of  Morphinism.  Cheapening  of  the  Drug 
Increased  Its  Use.  Danger  from  Teaching  Laymen 
Its  Use.  Morphinism  Due  to  Modem  Civihzation 
and  the  Strains  of  Constant  Excitement.  Neuras- 
thenia and  Cerebrasthenia  as  Active  Causes.  The 
Needle  Fascination  and  Mania.  Examples  of  Persons 
of  This  Class.  Use  of  the  Needle  Increasing.  Other 
Drugs  Used  with  Morphin  by  the  Needle.  Morphin 
Peddlers.     Injuries  from  the  Needle. 

CHAPTER  II 

Some  Distinctions,  Classifications,  and  Stages 42 

The  Term  "Morphinism"  Described.  Morphin:  How 
Taken.  Who  Are  Morphinists?  Who  are  Morphino- 
maniacs?  The  Two  Classes  and  Their  Relations. 
Thought  to  be  a  Moral  Disorder  by  Many  Persons. 
Fascinating  Effects  at  First.  Nervous  Invalids 
Most  Easily  Affected.  Morphin  Hunger.  What 
Constitutes  Morphinism?  Egotism  and  Cimning  in 
Explaining  the  Use  of  the  Drug.  First  Symptoms. 
First  Pathologic  Efifects.  Predispositions,  Hereditary 
and  Acquired.  Impairment  of  the  Higher  Brain. 
Three  Stages  of  Morphinism:  First,  When  Morphin 
is  Used  for  Some  Specific  Effect;  Second,  Morphin 
Used  for  Its  Mental  and  Physical  Effect;  Third, 
Where  Morphin  Cannot  be  Abandoned  without  Dis- 
comfort. Examples  of  These  Three  Stages.  Another 
Class  Who  Begin  and  Suddenly  Stop  the  Use  of  Mor- 
phin without  Any  Apparent  Cause.     Examples. 

II 


1 2  Contents 

CHAPTER  III  PACK 

Etiology;  Injuries;  Shocks;  Etc 56 

Study  of  the  Causes  Reveals  Only  Physical  Forces. 
Border-land  Neuroses.  Uniform  Causation.  Pro- 
gress and  Development.  Only  a  Few  of  the  Causes 
and  Laws  Which  Govern  Them  are  Known.  First 
Group  are  the  Neuroses  from  Inheritance.  Diathesis 
Coming^  from  Alcoholic,  Syphilitic,  Tuberculotic,  and 
Hysterical  Ancestors.  Varieties  and  Conditions. 
One  Class  Use  Morphin  for  Exhaustion;  Another,  for 
the  Pain  from  Injury  and  Disease.  Children  Show 
These  Defects.  Morphinism  a  Psychosis  Both  In- 
herited and  Acquired.  Mental  Defects  and  Char- 
acteristics. Atavism,  Precocity,  and  Mental  Insta- 
bility Prominent.  Other  Causes  are  Starvation,  In- 
toxication, Brain-strains,  and  Nervous  Drains.  Mor- 
phin Unpleasant  at  First.  Morphinism  from  Injury, 
Examples.  Autointoxications  Often  Causes.  Surgi- 
cal Operations.  Injuries  to  the  Cord.  Etherization 
Predisposes  to  Use  of  Morphin.  Danger  from  Mor- 
phin in  Gynecologic  Practice.  Shock  and  Excite- 
ment Causes.     Association  with  Alcohol. 

CHAPTER  IV 
Symptomatology;  Peculiarities;  Prognosis  and  Ter- 
mination         96 

First  Symptoms.  Psychologic  Action.  Stimulation 
and  Irritation.  Unconsciousness  of  Its  Effects, 
Efforts  to  Conceal  Its  Use.  Delusions  and  Illusions. 
Long-continued  Concealed  Use.  Appearance  of  the 
Eyes.  Emotional  Disturbances.  Stolidity  and  Ner- 
vousness. Appetite  and  Nutrition.  Bowels.  Mental 
Symptoms.  Changes  of  Character,  Habits,  and  Men- 
tal Activity.  Heart  Changes.  Mental  Instability 
and  Feebleness.  Delusions  of  Infidelity  Character- 
istic. Never  a  Leader,  but  Always  a  Critic.  Pro- 
gress Uniform  in  Many  Cases.  Unexpected  Death 
Common.  The  Higher  Brain  Suffers  Most.  Changes 
of  Symptoms.  Associated  Drugs.  Insanity  Symp- 
toms, Disability  to  Use  Other  Drugs  to  Conceal 
Their  Real  Condition,     Morbid  Fears  and  Manias, 

CHAPTER  V 

Diagnosis;  Prognosis;  Complications i33 

The  Eye,  The  Voice.  The  Manner,  The  Skin.  The 
Appetite.  Some  Means  of  Diagnosis.  Changes  in 
Appearance.  Egotism.  The  Prognosis.  Condi- 
tions Which  Determine  This.  Sudden  Changes.  Re- 
lapses. Other  Drug-taking.  Detection  in  the  Urine. 
Washing  Out  the  Stomach,     Examples, 


Contents  1 3 

CHAPTER  VI  PAGE 

Treatment;    Asylum    Conditions;    Drugs;    Hygienic 

Measures   150 

Control  of  Patient.  Removal  from  Home.  Private 
Asylums.  Seeking  New  Remedies  and  New  Methods 
of  Treatment.  Exaltation  and  Delusion.  Restraint 
and  Freedom.  Different  Methods  of  Withdrawal. 
How  They  Are  to  be  Applied.  Some  Remedies  to  be 
Used.  The  Needle  and  the  Use  of  Opium  as  a 
Remedy.  Narcotics  in  the  Treatment.  Insomnia; 
Its  Treatment.  Water  and  Its  Application.  Differ- 
ent Plans  of  Treatment.  The  Author's  Plan;  Its 
Details.  After  the  Treatment,  Psychic  Element  to  be 
Noted.  Placebos.  Time  of  Treatment.  Delusive 
Symptoms.  Theories  of  the  Withdrawal  Symptoms. 
Treatment  at  Home.  Cannot  do  Business  During  the 
Treatment.     Examples. 

CHAPTER  VII 

Opium-taking;  Its  Prevalence;  Diagnosis 197 

Use  of  Opium.  Differs  a  Little  from  Morphin.  Gen- 
eral Symptoms.  Different  Opinions  of  the  Danger  of 
Opium-taking.  De  Quincey's  Delusions  a  Slow  De- 
generation Following  Its  Use.  The  Psychic  Symp- 
toms Less  Prominent.  Pathologic  Symptoms.  Ef- 
fects on  Animals.  Opium- smoking;  Its  Fascination. 
Number  of  Persons  Suffering  from  Opium-smoking. 
Prognosis.  General  Treatment.  Deliritmi  from  This 
Source.     Delirium  from  Morphinism. 

CHAPTER  VIII 
Medicolegal  Relations  of  Crime  and  Responsibility  .  223 
Faulty  Mind  and  Senses.  Some  Examples.  Loss 
of  Consciousness.  Moral  Palsy.  Untruthfulness. 
Paralysis  of  the  Will.  The  Questions  of  Responsi- 
bility. Why  Morphinists  are  Irresponsible.  Re- 
sponsibility in  the  EKsposition  of  Property.  Responsi- 
bility in  Swindling  and  Fraud.  Selfishness.  Cannot 
be  Trusted  as  a  Witness.  Examples.  Need  of 
Medicolegal  Study.  Some  Strange  Cases.  Loss  of 
Memory.  Not  Often  Used  for  Criminal  Purposes. 
Some  Examples, 

CHAPTER  IX 
Medicolegal  Relations  of  Crime  and  Responsibility 

— (Continued)     244 

Clinical  Histories.  Failure  to  Understand  the  Degree 
of  Responsibility.  History  of  Inherited  and  Acquired 
Defects.     Psychic  Palsies.     Crime    Instincts   Promi- 


14  Contents 

nent.  Double  Personality.  Strange  Delusions.  Hal- 
lucinations and  Morbid  Impulses.  Opium  Not  Often 
Used  for  Criminal  Purposes. 


CHAPTER  X 

Cocainism:  Its  Etiology  and  Treatment 370 

First  Described  as  a  Disease.  Theories  of  the  Value 
of  Cocain.  Cheapening  the  Cost  of  Production.  Use 
by  the  Needle.  Extent  of  Its  Use.  Where  Sold. 
Two  Classes  Suffer  from  Its  Use  More  Than  Others. 
Early  Causes  of  Cocain  Habit  in  Previous  Spirit  and 
Drug  Addiction.  Different  Reasons  for  the  Use  of 
Cocain.  Two  Forms  of  Cocainism.  Some  General 
Symptoms.  Delusions  of  Strength  and  Vigor.  Later 
Symptoms.  Comparison  with  Morphinism.  Pathology 
and  Injurious  Effects.  Treatment  and  Legal  Care 
Necessary. 

CHAPTER  XI 

Chloralism:  Its  Etiology  and  Treatment 287 

Chloralism  Seen  in  Women.  Used  for  Insomnia.  Ir- 
regular Action  of  the  Heart  Follows.  Mistaken  for 
Other  Diseases.     Persons  Addicted. 


CHAPTER  XII 

Chloroformism:  Its  Etiology  and  Treatment 293 

More  Common.  Follows  from  Neurotic  States.  Used 
for  Specific  Pain.  After  the  Paroxysm  Repulsion 
Follows.  Periodicity.  Secrecy.  Tetanoid  Symp- 
toms Follow.  Treatment.  Change  of  Surroundings 
Required.      Prognosis.      Remedies  Useftil. 


CHAPTER  XIII 

Coffee  Addiction    303 

Its  Peculiar  Symptoms.  Questions  of  Medicolegal 
Interest,  which  Come  from  Such  Cases.  Associated 
with  Other  Addictions.    .Effects  on  Yotmg  Persons. 

CHAPTER  XIV 

Tea  Inebriety    311 

Is  Increasing.  A  Most  Complex  Neurosis  Affecting 
Large  Numbers  of  Women.  Pecvdiar  Symptoms 
which  are  Often  Mistaken  for  Other  Diseases.  Treat- 
ment and  Prevention. 


Contents  1 5 

CHAPTER  XV  PAGE 

Tobacco  Inebriety   315 

The  Poison  of  Tobacco.  Symptoms  of  Tobacco  In- 
toxication. Often  Associated  with  Alcohol  and  Other 
Drugs.  Tobacco  Narcotic  Poisoning.  Its  Use  in 
Any  Form  Followed  by  Debility  and  Exhaustion. 
Tobacco  to  be  Abandoned  in  the  Treatment  of  Drug 
Addictions.  Often  an  Exciting  Cause  to  Other  Nar- 
cosis. Very  Complex  and  Very  Difficult  of  Treat- 
ment. The  Cigarette  Habit.  Its  Prevalence  and 
Danger  as  Noted  by  Statistics.  Analysis  of  the 
Cigarette.  Poisons  which  It  Contains.  Its  Imme- 
diate Effects.  The  Treatment  of  Cigarette  Disease. 
Medicolegal  Questions  which  Come  from  It. 

CHAPTER  XVI 

Ether  Inebriety   322 

Confined  to  Certain  Localities.  Seen  in  North  of 
Ireland.  Its  Effects.  Easily  Discovered.  Cordials 
Containing  Ethers  Used.  Cordials  are  Adtilterated 
Extracts.  Ethers  not  always  Stimulants.  Often 
Narcotics.       Always  Dangerous. 

CHAPTER  XVII 

Addictions  from  Other  Drugs    327 

Arsenic.  Trional.  Antipyrin.  Ginger.  Cologne. 
Gelsemium.  Sulfonal.  Paraldehyd.  Lavender. 
Capsicum. 

CHAPTER  XVIII 

Some  Conclusions   339 

Different  Drug  Addictions.  Narcomaniacs  Common. 
Medicolegal  Interest.  Public  Treatment.  Private 
Treatment.      Colony  Settlements. 


Index 345 


MORPHINISM 


CHAPTER  I 
THE  HISTORY  OF  MORPHINISM 

Early  History  of  Opium.  Its  Use  as  a  Sedative  and  Narcotic. 
Some  Theories  of  Its  Value.  The  First  Book  on  This  Subject. 
Later  Papers  and  Theories.  Use  Externally  through  the  Skin. 
Early  Use  of  the  Syringe.  First  Use  of  Morphin.  Recognition 
of  the  Danger  of  Morphin  by  the  Needle.  Early  Writers  and 
Their  Views.  First  Classification.  Its  Prevalence  in  Europe 
and  This  Country.  Chemical  Properties  of  Morphin.  Classes 
of  Persons  Using  It.  Use  among  Physicians.  Difficulties  in 
Determining  the  Extent  of  Morphinism.  Cheapening  of  tlte  Drug 
Increased  Its  Use.  Danger  from  Teaching  Laymen  Its  Use. 
Morphiftism  Due  to  Modern  Civilization  and  the  Strains  of  Con- 
stant Excitement.  Neurasthenia  and  Cerebr asthenia  as  Active 
Causes.  The  Needle  Fascination  and  Mania.  Examples  of 
Persons  of  This  Class.  Use  of  the  Needle  Increasing.  Other 
Drugs  Used  with  Morphin  by  the  Needle.  Morphin  Peddlers. 
Injuries  from  the  Needle. 

The  original  home  of  the  poppy  appears  to  have 
been  in  the  valley  of  the  Nile.  The  first  mention 
of  its  use  was  found  in  hieroglyphics  dating  back 
to  a  very  early  stage  of  Egyptian  civilization. 
Homer  describes,  in  the  fourth  book  of  the  "Odys- 
sey," a  drug,  which  was  evidently  opium,  sent  to 
Helen  from  the  wife  of  Thone,  an  Egyptian  king. 

2  17 


1 8  Morphinism 

Hippocrates  was  among  the  first  authors  who 
recommended  its  use  internally.  About  his  time  it 
was  condemned  because  of  its  effects  on  the  vision 
and  the  great  and  unnatural  somnolence  which  it 
produced. 

In  those  early  days  one  Ange,  evidently  a  priest, 
used  this  drug,  and  its  effects  were  so  pleasing  to 
him  that  he  became  very  enthusiastic  in  proclaim- 
ing its  value  to  the  world. 

There  are  many  curious  legends  concerning  the 
discovery  of  the  effects  of  opiimi.  One  of  these 
describes  an  Egyptian  prince  who  was  lost  on  a 
hunting  tour  and  was  carried  exhausted  to  a  hut 
and  placed  on  a  bed  of  poppy  leaves,  upon  which 
he  slept  for  two  days ;  he  then  awakened  with  un- 
usual vigor.  This  story  seems  to  have  been  credited, 
and  to  have  formed  the  basis  of  many  theories  con- 
cerning the  value  of  poppy  leaves  as  a  remedy  direct 
from  the  hands  of  the  Deity. 

In  a  very  early  age  there  appears  to  have  been 
much  rivalry  concerning  the  superiority  of  opiiun 
cultivated  about  Thebes,  called  Thebaic  opium,  and 
that  grown  in  Persia  near  Ispahan,  called  Persian 
opium.*  Several  authorities  described  the  differ- 
ences in  detail,  saying  that  the  Persian  opium.  "  pro- 
duced crudities  in  the  stomach"  and  was  not  sooth- 
ing like  the  Thebaic  opium.     The  difference  in  price 

*  "  Opium  and  Its  Effects."     Leigh. 


The  History  of  Morphinism  19 

at  Constantinople  is  mentioned  as  evidence  of  the 
value  of  the  Thebaic  opium.  In  those  early  times 
many  authors  disputed  as  to  whether  opium  came 
from  the  white  or  the  colored  poppy,  or  whether  it 
was  the  meconium  of  the  Egyptians. 

It  was  probably  used  to  produce  sleep  and  to 
quiet  the  brain  and  nervous  system.  The  priests 
believed  that  in  some  way  it  led  the  mind  into  the 
spiritual  world,  and  that  the  sleep  following  its  use 
was  a  bridge  to  connect  the  soul  with  the  home 
of  the  gods.  One  of  the  Persian  proverbs  declared 
that  opium  taken  internally  was  a  remedy  for  many 
diseases,  and  that  it  also  produced  a  disease. 

Historically,  the  use  of  opium  as  a  medicine 
began  in  the  first  centuries  of  the  Christian  era; 
and  it  appears  to  have  been  given  for  the  removal 
of  pain  and  discomfort.  The  discovery  of  the 
value  of  the  juice  and  the  extract  was  probably 
made  by  the  Greeks. 

The  growth  and  use  of  the  plant  seemed  to  spread 
very  rapidly  eastward,  probably  by  those  ancient 
traders,  the  Arabs.  In  this  way  it  passed  into 
Persia,  India,  Java,  and  China,  where  it  has  had 
a  firm  foothold  ever  since.  By  the  early  medical 
men  opitun  was  called  a  stimulant,  and  its  seda- 
tive effects  were  thought  to  be  prophylactic  and 
preventive.  It  was  used  as  both  a  domestic  and 
a  special  remedy. 


20  Morphinism 

The  Arabian  physicians  seemed  to  have  made 
the  first  studies  of  its  value  in  diseases,  using  a 
decoction  of  the  plant  which  was,  no  doubt,  that 
of  the  bruised  leaf  and  seed-pod,  or  an  infusion  made 
from  the  crushed  stems.  The  soothing  effect  of 
this  watery  extract  was  more  marked  than  that  of 
any  other  drug.  For  a  long  time  opium  was  used 
as  a  remedy  with  widely  varying  popularity,  al- 
though always  invested  in  myth  and  conjecture. 
Its  narcotic  effects  were  explained  by  all  sorts  of 
theories,  and  the  plant  was  studied  with  supersti- 
tious reverence.  The  literature  is  a  curious  medley 
of  shrewd  conjecture  and  fanciful  theories  concern- 
ing its  effects  and  action  on  the  brain  and  body, 
lacking  in  moderate  scientific  spirit. 

The  period  of  exact  study  begins  with  the  last 
century;  and  while  the  sociologic  and  moral  effects 
of  opium-taking  have  attracted  much  attention,  the 
exact  medical  study  has  not  advanced  very  far, 
and  is  still  a  neglected  field.  A  century  ago,  in 
1786,  "Opium  and  Its  Effects"  was  the  subject  of 
a  prize  essay  by  Dr.  John  Leigh  before  the  Harveian 
Society,  England.  This  essay  had  a  wide  circulation 
at  the  time,  and  was  the  beginning  of  a  new  litera- 
ture. It  described  opium  and  its  value  in  a  variety 
of  diseases,  giving  experiments  and  details,  proving 
its  usefulness  in  many  ways.  This  book  was 
dedicated  to  George  Washington,  and  many  copies 


The  History  of  Morphinism  21 

were  sent  to  this  country,  some  of  which  may  yet 
be  found  in  the  libraries. 

In  many  sections  of  Europe  the  poppy  was  cul- 
tivated, and  used  as  a  domestic  remedy  for  pain 
and  headaches  and  general  diseases.  According  to 
some  old  books  and  papers,  it  was  widely  used, 
principally  for  its  effects  in  suppressing  dysentery 
and  diarrhea.  One  of  the  earliest  attempts  to  use 
opium  was  advocated  in  a  little  book  published  in 
1809  by  Dr.  Ward,  of  Manchester,  England.  He 
claimed  that  opium  (probably  a  solution  evaporated 
to  a  paste)  rubbed  on  the  skin  would  be  absorbed 
by  the  lymphatics,  and  thus  allay  irritation  and 
pain  and  produce  sleep  more  pleasantly  than  by 
any  other  method.  This  was  no  doubt  the  first 
reference  to  what  eventually  became  the  hypoder- 
matic use  of  opium  and  its  alkaloids. 

In  1855,  Dr.  Wood,  of  Edinburgh,  advised  making 
an  incision  in  the  skin  and  injecting  the  drug  into 
the  tissue.  Before  that  time,  in  1838,  Dr.  Rolland, 
an  English  physician,  praised  the  use  of  opium  paste 
for  local  neuralgias;  also  for  painful  sores.  Later 
a  syringe  was  used  by  which  a  watery  solution  of 
opium  was  injected.  From  this  time  the  syringe 
came  into  use  for  the  purpose  of  introducing  medi- 
cines under  the  skin,  and  was  supposed  to  be  a 
very  great  advance  in  the  therapeutics  of  that  day. 

Anstie  and  others  wrote  at  some  length,  praising 


22  Morphinism 

this  method  for  its  economy  and  freedom  from 
irritant  effects.  It  was  also  claimed  to  be  more 
rapid  and  permanent,  and  to  interfere  less  with 
the  functions  of  the  body  than  any  other  method 
of  administration.  Therapeutic  authorities  in  those 
days  urged  that  hypnotics  or  anodynes  should  never 
be  administered  by  the  mouth  in  acute  diseases 
attended  with  anorexia. 

The  discovery  of  the  chemical  properties  of  opium 
makes  an  interesting  page  of  medical  history. 
The  poppy  plant  and  opium  had  attracted  so  much 
attention  by  its  wide  range  of  usefulness  that  the 
attention  of  chemists  was  early  drawn  to  it.  Dr. 
Luria,*  in  his  recent  essay  on  opium,  says: 

"  From  the  dawn  of  the  last  century  our  best  and 
most  eminent  physiologic  chemists  have  devoted 
special  care  and  attention  to  the  study  of  this  most 
marvelous  plant.  To  the  indefatigable  researches  of 
these  pioneers  in  the  field  of  physiologic  chemistry 
the  medical  world  owes  a  great  deal  of  gratitude,  as 
their  investigations  into  the  nature  of  the  poppy 
plant  carried  them  to  the  discovery  of  those  vege- 
table alkaloids  which  have  proved  to  be  the  active 
principles  of  the  plants  wherein  they  are  found, 
and  that  since  have  had  such  a  remarkable  success 
in  the  treatment  of  disease.     The  honor  and  the 

♦"Morphine  and  Its  Alkaloids,"  by  Dr.  Ltiria.  "Merck's 
Archives,"  April  and  July,  1901. 


The  History  of  Morphinism  23 

credit  of  having  been  the  pathfinder  of  this  new 
era  of  investigation  belong  to  the  apothecary 
Sertumer,  at  Einbeck,  in  the  province  of  Hanover, 
Germany.  The  seed  sown  by  Sertumer  fell  upon 
fruitful  soil,  and  thus,  in  1803,  Derosne  announced 
to  the  scientific  world  his  discovery  of  a  cry'stalline 
body  that  he  obtained  from  opium,  and  which  he 
called  the  'salt  of  opium,'  believing  it  to  be  the 
active  principle  of  the  drug.  But  such  was  not  the 
case,  as  was  later  demonstrated  by  Robiquet.  In 
1804  Seguin  isolated  another  crystalline  body, 
which  time  and  experience  have  proved  to  be  the 
real  narcotic  principle  of  opium.  But  Seguin  did 
not  realize  the  importance  of  his  discovery,  only 
considering  it  as  a  mere  scientific  curiosity,  which, 
however,  attracted  but  little  attention.  Thus  the 
matter  remained  quiescent  until,  in  181 7,  Sertumer 
again  proclaimed  the  existence  of  a  saline  compound 
in  opium,  endowed  with  a  peculiar  alkaline  prin- 
ciple and  united  to  a  peculiar  acid,  thus  clearly 
demonstrating  the  real  nature  of  the  substance 
discovered  by  Seguin  and  himself  a  little  over  a 
decade  before.  This  salt,  destined  to  play  an 
important  role  in  modem  therapeutics,  he  called 
'morphium.'" 

A  description  of  the  other  alkaloids  and  deriva- 
tives of  opium  will  show  the  value  of  this  plant: 
"  Besides  morphin,  which  exists  in  opium  with  sul- 


24  Morphinism 

phuric  and  meconic  acid,  there  is  also  to  be  found 
in  it  a  certain  amount  of  lactic  acid;  but  this  is 
held  by  many  chemists  to  be  only  an  accidental 
constituent  originating  during  or  subsequent  to 
the  process  of  the  collection  of  the  juice.  In  the 
course  of  time  several  other  tJasic  substances  have 
been  isolated  from  different  varieties  of  opium,  but 
their  amount  rarely  exceeds  i  per  cent.  Among 
these  is  to  be  named  the  oldest  alkaloid,  the  one 
that  was  discovered  in  1803  by  Derosne  and  named 
by  Robiquet  *  narcotin,'  a  name  which  it  still  retains. 
It  exists  in  amounts  varying  from  2  to  4  per  cent. 
Then  narcein,  codein,  thebain,  papaverin,  meconin, 
cryptopin,  meconidin,  hydrocotamin,  laudanosin, 
protopin,  laudanin;  also  a  few  other  bodies  of  a 
feebly  alkaline  or  neutral  nature,  as  lanthopin,  etc. 
Besides,  there  are  several  derivatives.  The  most 
important  so  far  derived  from  morphin  is  called 
apomorphin.  All  the  organic  bases  of  opium  pro- 
duce a  deviation  of  the  plane  of  polarization  to  the 
left.  Opium  contains,  besides,  in.. no  mean  amounts, 
several  resinoid  bodies.  Furthermore,  it  exhibits 
a  variable  amoimt  of  mucilage,  a  gum  distinct  from 
the  ordinary  gum-arabic.  It  also  contains  pectin, 
albumin,  and  a  waxy  material  consisting  chiefly  of 
palmitate  and  creotate  of  cerotyl;  also  calcareous 
salts  in  amounts  varying  from  4  to  8  per  cent. 
Not  infrequently  sugar  is  also  found  in  opiirni,  but 


The  History  of  Morphinism  25 

the  question  yet  awaits  solution  whether  this  is  a 
natural  constituent  of  the  opium  or  whether  it  forms 
a  part  of  the  adulteration  of  the  drug.  The  amovmt 
of  mucliage  present  influences  the  value  of  opium 
for  smoking  purposes  a  good  deal,  since  the  Chinese 
estimate  its  value  roughly  by  the  mere  'touch'; 
that  is  to  say,  they  gage  it  by  the  rapidity  or  slow- 
ness with  which  a  thread  drawn  out  from  the  mass 
will  break  by  its  own  weight.  These  are  the  prin- 
cipal chemical  constituents  of  opium,  of  which 
morphin  and  codein  are  quite  extensively  used  in 
medicine,  while  narcein  has  found  favor  with  a  few 
physicians.  Narcotin  itself  is  practically  never  used ; 
but  a  derivative  of  it,  cotarnin,  is  very  much  used 
at  present  as  a  hemostatic.  Its  hydrochlorate  is 
known  as  stypticin,  and  is  employed  extensively  in 
menorrhagia,  metrorrhagia,  subinvolution,  hemop- 
tysis, etc.  Its  (stypticin's)  dose  is  from  f  to  2 
grains,  and  it  may  be  given  in  pill  form,  in  solution, 
or  hypodermically." 

Opium  had  been  given  subcutaneously  in  the  form 
of  pastes  or  injected  as  a  watery  solution  under  the 
skin  for  a  long  time.  One  of  the  earliest  references 
to  the  use  of  morphin  in  this  country  was  by  Drs. 
Isaac  Taylor  and  Washington,  of  New  York.  In 
1839  in  dispensary  practice  it  was  given  with  a 
syringe  for  various  purposes.  In  1843  Drs.  Wood 
and  Rynd  made  a  solution  of  morphin  to  be  used 


26  Morphinism 

by  'the  needle.  Fordyce  Barker,  in  1856,  brought 
over  from  Edinburgh  a  small  syringe  by  which  he 
used  morphin  imder  the  skin.  Tiemann  began  to 
make  needles  about  this  time,  patterned  after  the 
one  of  Barker. 

In  1864,  the  "Lancet"  published  a  number  of 
articles  pointing  out  the  danger  of  the  use  of 
morphin  as  an  addiction.  This  was  probably  the 
first  warning  note  against  its  use. 

In  1866  Pravaz  introduced  into  the  French  army 
a  compact  little  syringe  by  which  morphin  was  in- 
jected under  the  skin,  in  the  treatment  of  wounds  in 
both  field  and  hospital.  This  popularized  its  use, 
and  from  that  time  the  use  of  morphin  by  the 
syringe  has  extended  widely  to  all  classes.  Enthusi- 
astic physicians  used  the  needle  for  nearly  all  con- 
ditions of  pain,  and  wrote  praising  this  method  of 
treatment.  Several  elaborate  papers  appeared  giving 
minute  accounts  of  the  best  methods  of  using  morphin 
by  the  needle.  Elaborate  theories  of  the  physiology 
of  the  drug  administered  in  this  way,  and  the 
technique  of  its  administration,  multiplied  rapidly, 
and  for  a  long  time  occupied  much  space  in  medical 
literature.  Occasionally  some  one  pointed  out  bad 
results  from  its  use,  but  this  attracted  little  atten- 
tion. Finally  a  book  on  this  subject,  by  Dr.  Kane, 
soimded  a  strong  note  of  warning  in  the  conclusion 
that  morphin  should  never  Be  used  hypQdermically 


The  History  of  Morphinism  27 

in  chronic  disease  of  the  kidneys,  and  that  it  was 
dangerous  in  delirium  tremens  and  mania;  also 
that  its  use  in  anemia  and  diseases  of  the  lungs  was 
full  of  peril. 

In  1864  Nausbaum  appears  to  have  been  the  first 
of  the  German  physicians  to  call  attention  to  the 
injurious  effects  of  repeated  injections  of  morphin. 
From  this  time  the  literature  of  this  subject  at- 
tracted attention.  A  few  cases  were  reported  of 
ill  effects  following  the  injection  and  its  continu- 
ous use  afterward,  but  these  were  considered  anom- 
alies, and  explained  as  caused  by  the  weak  will 
of  the  patient. 

In  1870  Dr.  Allbutt  published  in  "The  Practi- 
tioner" a  strong  paper  pointing  out  the  danger 
from  repeated  injections  of  morphin,  and  the  diffi- 
culty of  restraining  the  patient.  He  distinctly 
showed  that  while  this  drug  relieved  the  severe  pain 
for  which  it  might  be  given,  it  caused  an  artificial 
craving  with  marked  symptoms  of  poisoning.  This 
was  probably  the  first  outline  of  morphinism  as  an 
intoxication  and  disease.  Later,  Laher,  Fielding, 
Hirschfeld,  Michel,  and  others  wrote  confirming 
these  statements,  giving  examples  to  sustain  their 
views. 

In  1877  and  1879  Lewenstein  wrote  a  monograph 
on  morphinism.  His  work  contained  the  best 
account  of  this  disease  up  to  that  time.     Dr.  Clark, 


28  Morphinism 

in  1879,  gave  in  the  "Lancet"  a  good  description 
of  the  withdrawal  symptoms  of  morphinism,  and 
Griffiths,  in  the  "Guy's  Hospital  Reports"  of  that 
year,  confirmed  and  added  to  this  a  clinical  history 
of  cases. 

From  this  time  on  a  great  many  writers,  both  at 
home  and  abroad,  have  described  these  cases  and 
some  of  the  symptoms  with  more  or  less  minuteness 
and  accuracy.  Drs.  Parrish  and  Mattison,  in  this 
country,  contributed  excellent  papers:*  Parrish,  on 
the  philosophy  and  causation  of  opium  addiction; 
Mattison,  on  methods  of  treatment. 

In  Germany,  writers  began  to  classify  and  describe 
the  disease.  According  to  Regnier,  they  could  all 
be  divided  into  two  classes:  Those  who  could  stop 
the  use  without  suffering,  and  those  who  had  gone 
beyond  this  stage,  where  the  craving  was  irre- 
sistible. Another  writer  made  three  classes :  Those 
who  use  morphin  for  pain;  those  who  continue  it 
after  the  causes  have  been  removed;  and  those 
who  use  it  for  the  pleasure  which  it  gives,  A 
number  of  authorities  finally  settled  upon  two 
classifications :  one  in  which  the  morphin  was  used 
for  pain;  and  the  other  for  pleasure. 

Later  researches  have  thrown  doubt  upon  these 
distinctions.     All    modem    writers    recognize    the 

*  "  Diseases  of  Inebriety."  Crothers.  E.  B.  Treat  &  Co., 
1893. 


The  History  of  Morphinism  29 

rapid  growth  of  this  disease  and  its  prevalence  where 
it  is  least  expected.  The  possibility  of  concealing 
its  use  for  many  years  has  made  it  a  most  seductive 
addiction.  Its  use  is  prevalent  in  France  and  Ger- 
many, where  entire  villages  are  said  to  be  filled  with 
morphin-takers. 

From  the  amount  of  morphin  consumed  in  un- 
known ways,  evidently  there  is  a  very  large  number 
of  habitues  in  the  United  States.  The  sale  of 
morphin  in  some  large  cities  indicates  that  not  half 
of  the  amount  sold  is  traceable  to  legitimate  de- 
mands by  physicians  and  hospitals.  The  enormous 
balance  is  consumed  in  some  unknown  way.  Statis- 
tics of  the  sales  of  drug-stores  show  that  a  very 
large  part  of  the  total  is  bought  by  laymen.  In 
one  village  in  central  New  York  a  small  drug-store 
sold  forty  ounces  a  month.  In  towns  where  there 
is  no  restriction  on  the  retail  sale  of  morphin,  certain 
stores  sell  regularly  large  quantities  to  persons  who 
are  known  to  be  addicted  to  its  use. 

It  is  said  that  the  regular  morphin  constmier 
patronizes  several  stores  from  one  to  two  years; 
then  changes,  going  to  some  other  place.  Often 
these  rounders  are  known  to  many  druggists,  who 
sell  them  small  quantities  daily  or  weekly  until 
they  appear  to  be  diseased;  then  the  drug  is 
refused.  Not  being  able  to  purchase  it  themselves, 
they  buy  through  an  agent. 


30  Morphinism 

There  are  large  numbers  among  the  lower  classes 
of  the  great  cities  who  consume  morphin  constantly. 
Some  local  statistics  would  seem  to  indicate  that 
business  men,  speculators,  and  persons  who  lead  a 
life  of  excitement  are  among  the  prominent  con- 
sumers. The  broken-down  alcoholics  are  known  to 
contribute  a  large  proportion  of  their  numbers  to 
this  class  of  purchasers.  One  author  asserts  that 
merchants,  lawyers,  physicians,  and  politicians, 
with  women  of  the  leisure  class,  are  the  most  numer- 
ous of  the  drug-takers. 

Some  recent  statistics  indicate  that  the  medical 
profession  furnishes  a  large  proportion  of  cases.  In 
France  and  Germany,  among  the  morphin  cases 
known,  the  physicians  are  most  prominent.  In  a 
study  of  3244  physicians  in  this  country  10  per 
cent,  were  estimated  as  either  secret  or  open  users 
of  the  drug.*  These  figures  are  sustained  by  a  great 
variety  of  evidence  from  many  sources. 

It  is  difficult  to  determine  the  extent  of  morphin- 
ism in  any  one  occupation  in  this  country.  One 
reason  is  that  many  persons  in  different  situations 
after  a  few  years'  addiction  to  morphin  become 
invalids  and  die  from  other  diseases,  the  morphinism 
not  being  recognized  as  the  original  cause.  It  has 
been  asserted  that  there  are  over  a  hundred  thou- 
sand   persons    constantly   using    morphin    in    this 

*"  Medical  Record."     Crothers.     November,  1899, 


The  History  of  Morphinism  31 

country  alone.  This  assertion  is  sustained  by  a 
careful  study  of  comparative  statistics. 

From  hospital  and  drug-store  statistics  it  is 
evident  that  the  percentage  of  persons  using  mor- 
phin  varies  widely  in  different  towns.  One  of  the 
collected  lists  of  addresses  for  sale  is  that  of  ten 
thousand  morphin-takers.  While  it  is  impossible 
to  verify  such  lists,  it  is  evident  that  they  represent 
the  most  noted  and  confirmed  cases,  and  do  not 
include  the  pauper  or  tramp,  whose  presence  is  so 
familiar  in  the  large  cities  during  the  winter.  In 
all  probability  they  belong  to  the  middle  and  lower 
classes,  with  a  sprinkling  of  wealthy  persons  who 
are  chronic  cases. 

Ordinarily  not  one-tenth  of  the  cases  of  mor- 
phinism are  known  to  any  except  their  most  intimate 
friends.  Some  authorities  believe  that  even  less 
than  this  percentage  is  known,  and  therefore  un- 
suspected. Statistics  in  certain  localities  sustain 
this  assertion. 

In  all  probability,  morphin  is  the  drug  most 
commonly  used.  Opium,  in  the  powder  or  tinc- 
ture, is  not  a  popular  addiction,  and  comparatively 
few  persons  depend  on  this.  All  morphinists  turn 
to  opium  when  they  cannot  get  the  former  drug; 
or  when  they  are  unable  through  poverty  to  buy 
anything  else,  will  use  laudanum  or  paregoric;  and 
if  still  further  reduced,  cultivate  the  poppy  for  its 


32  Morphinism 

crude  gum.  Wholesale  drug-houses  in  certain  cities 
have  an  enormous  trade  in  morphin,  and  in  dif- 
ferent sections  of  the  country  the  sales  are  far 
beyond  the  natural  demand. 

The  cheapening  of  this  drug  has  undoubtedly  in- 
creased its  use,  and  wherever  it  can  be  procured 
without  much  difficulty,  there  the  demand  is  in- 
creasing. On  the  frontiers  and  in  centers  of  great 
business  excitement  and  nervous  strain  it  is  used 
more  and  more. 

No  doubt  irresponsible  and  irregular  doctors  con- 
tribute very  largely  to  the  spread  of  this  addiction. 
The  custom  a  few  years  ago  of  teaching  patients 
to  use  the  needle  and  furnishing  them  with  the 
drug  to  relieve  states  of  neuralgia  and  unexpected 
pain  paroxysms  was  very  dangerous.  This  practice 
undoubtedly  made  many  morphin  victims.  Foolish 
physicians  who  thought  the  whole  province  of 
medicine  was  to  relieve  pain  under  all  circumstances, 
and  who  used  morphin  in  a  routine  way,  have  made 
many  victims  of  this  class.  Many  quack  medicines 
for  the  relief  of  pain  contain  morphin,*  and  when 
this  is  discovered,  the  purchaser  buys  the  drug 
direct,  and  its  use  is  continued. 

Probably  morphinism  as  a  disease  is  due  in  a  large 
measure  to  modem  civilization,  associated  with  the 
rapid  exhaustion  following  changes  of  life  and  living ; 

*  "  Journal  of  Inebriety."     January,  1890. 


The  History  of  Morphinism  33 

also  from  absence  of  nerve  rest,  and  the  continual 
strain  upon  the  organization  in  its  effort  to  become 
adapted  to  new  environment.  This  is  accompanied 
by  discomfort  and  pain,  for  which  morphin  is  a  tem- 
porary alleviation.  The  impression  once  made  of 
rest  and  removal  of  suffering  is  rarely  effaced,  and 
the  desire  to  resort  to  the  remedy  again  imder 
stress  is  so  great  as  to  be  finally  irresistible. 

Morphinism  is  a  modem  disease,  and  threatens  to 
be  one  of  the  most  serious  menaces  accompanying 
twentieth  century  civilization.  Neurasthenia  and 
cerebrasthenia  are  new  differentiations  of  nervous 
defects  incident  to  the  times;  and  morphin  is  the 
new  solace  which  gives  temporary  relief  and  con- 
ceals the  real  condition  while  intensifying  and  in- 
creasing it. 

Some  literary  writers  have  given  vivid  descriptions 
of  the  effects  of  opium  on  themselves  and  have 
,  conveyed  the  impression  that  its  use  within  certain 
limits  was  not  harmful.  The  gum,  powdered 
opium,  infusion,  or  tincture  was  used,  often  in  large 
quantities.  De  Quincey  was  able  to  use  at  one  sitting 
a  quart  of  laudanum.  This  habit  he  could  abandon 
at  times  without  assistance,  resuming  it  again  readily. 
Had  he  used  morphin  with  the  needle,  the  quantity 
required  would  have  been  less,  but  he  never  could 
have  abandoned  it. 

The  fascination  of  the  needle  is  profound  and 
3 


34  Morphinism 

wide-reaching,  and  in  most  cases  the  rapidity  and 
certainty  of  its  effects  "without  unpleasant  conse- 
quences leave  a  mental  impression  not  easily  effaced. 
There  is  a  certain  contagion  associated  with  the 
prick  of  the  needle,  and  the  restful  calm  which 
follows  is  both  physiologic  and  psychic  in  its  effects. 
It  is  now  well  recognized  that  there  is  a  needle  mania 
demanding  that  drugs  be  used,  confident  that  their 
power  will  be  increased  and  their  action  be  more 
certain  and  rapid  in  this  way. 

In  the  treatment  of  morphinism  where  this  needle 
mania  is  present,  injections  of  water  are  often  equaUy 
efficacious  and  satisfactory.  This  mania  is  likely 
to  occur  in  neurotics  who,  when  suffering  from  other 
diseases,  have  obtained  marked  relief  from  drugs 
given  in  this  manner.  The  impression  is  so  pro- 
nounced that  ever  afterward  the  same  means  are 
used  and  the  same  results  sought  for.  Some 
psychologic  effect  has  produced  on  the  brain  and 
nerve-centers  a  profound  conviction  of  the  value 
and  power  of  medicines  so  given.  Some  examples  of 
this  needle  mania  will  be  interesting. 

A  man  of  culture,  a  neurotic,  and  of  intense 
nervous  organization,  became  a  morphinist  through 
the  pain  and  sequels  of  intermittent  fever.  He  was 
treated  at  home,  and  the  morphin  removed,  but 
the  use  of  the  needle  was  continued.  When  this 
was  stopped,  he  became  excessively  nervous,  in- 


The  History  of  Morphinism  35 

somniac,  and  suffered  from  great  depression  of 
spirit.  His  family  physician  finally  prepared  some 
distilled  water  and  ordered  its  use  three  times  a  day 
as  a  medicine.  The  patient  has  continued  this  for 
several  years,  and  is  in  very  much  improved  health 
and  attends  to  business  with  but  little  change.  He 
takes  two  injections  a  day  with  great  regularity, 
and  actually  suffers  if  he  does  not  get  them.  The 
physician,  recognizing  his  credulity,  thinks  it  wiser 
to  treat  it  than  to  break  it  up  and  cause  him  to 
depend  on  some  other  more  dangerous  method  of 
treatment. 

The  second  example  is  that  of  a  woman  in  middle 
life,  who,  after  a  severe  surgical  operation,  and  per- 
sistent pain  for  a  long  time,  became  a  morphinist. 
She  was  treated  successfully  in  an  asylum,  the  mor- 
phin  removed,  but  on  her  return  hom.e  she  became 
possessed  with  the  idea  that  something  might  happen 
to  her  heart  and  she  might  die  before  help  could  be 
procured.  She  begged  of  the  physician  to  give  her 
a  needle  and  a  morphin  solution,  that  she  might  use 
it  to  avoid  this  danger.  She  was  very  earnest  in  her 
fears  of  contracting  an  addiction,  and  for  a  time, 
when  these  obsessions  came  upon  her,  consented  to 
have  the  physician  use  the  needle.  When  it  was 
found  that  her  fears  were  hysterical,  the  physician 
prepared  a  bitter  water  solution  and  gave  her  a 
needle  with  strict  injunctions  not  to  use  it  except  as 


36  Morphinism 

a  last  resort.  This  she  has  continued  to  do  for 
four  years,  only  occasionally  using  the  needle,  and 
always  with  the  greatest  benefit.  When  the  threat- 
ened collapse  appears,  she  struggles  against  it  for  a 
few  hours,  then  finally  uses  the  needle,  obtains  reHef , 
and  sleeps  for  a  time.  On  awakening,  she  is  calm, 
but  filled  with  dread  that  she  may  use  it  again  and 
thus  become  addicted  to  its  use.  The  mind  is 
occupied  with  efforts  and  fears  to  prevent  the  return 
of  the  conditions  which  call  for  the  needle.  This 
passes  off  in  a  day  or  so ;  then  a  long  uncertain  in- 
terval follows  in  which  no  fears  or  fancied  dangers 
appear.  The  family  physician,  by  advising  active  hy- 
gienic measures  and  much  outdoor  life,  has  succeeded 
in  breaking  up  the  fear  of  heart  failure  to  a  large 
extent;  hence  the  use  of  the  needle  is  less  fre- 
quent. 

The  writer  was  called  in  consultation  with  a 
physician  who  had  for  two  years  been  giving  a 
patient  water  by  the  needle  for  an  imaginary  brain 
trouble.  The  patient  had  been  a  mild  morphinist. 
The  drug  had  been  removed,  but  the  use  of  the 
needle  could  not  be  abandoned.  The  physician  had 
tried  many  ways,  but  had  failed.  When  the  injec- 
tions were  not  given  regularly,  extreme  prostration 
and  hysterical  dread  of  death  and  pain  filled  the 
victim's  mind,  also  fears  of  poisoning  and  injury 
from    drugs    given    by    the    mouth.      When    the 


The  History  of  Morphinism  -y^*] 

needle  was  resumed,  all  this  passed  away,  and 
the  patient  was  able  to  be  up  and  to  attend  to  some 
business.  The  result  of  most  elaborate  efforts  to 
break  up  this  addiction  was  that  the  patient  was 
obliged  to  have  two  injections  a  week  given  by  the 
physician.  This  seemed  satisfactory,  and  has  been 
continued  up  to  the  present  time, 

A  fourth  example  of  the  same  class  brings  out 
the  domination  of  an  idea  and  its  controlling  in- 
fluence over  a  mind  which  shoiild  be  able  to  dis- 
criminate. A  lawyer  and  judge,  an  active  and 
overworked  man,  living  unhygienically,  became  im- 
pressed with  the  idea  that  only  drugs  by  the  needle 
could  produce  any  permanent  effect  on  the  body. 
This  came  from  reading  a  monograph  written  by 
an  enthusiastic  physician  to  prove  that  drugs  given 
in  this  way  could  not  injure  the  system  and  that 
the  beneficial  effects  were  more  rapid  and  certain. 
The  family  physician,  recognizing  his  whim,  con- 
sented to  treat  him  with  the  needle  on  his  promise 
not  to  use  anything  except  what  he  should  give 
him.  Pie  began  to  give  him  injections  of  colored 
water,  and  at  the  same  time  to  ad\4se  certain  changes 
in  his  diet  and  work.  The  result  was  very  marked. 
The  patient  recovered,  but  the  injections  were  con- 
tinued. For  the  next  five  years  whenever  he  felt 
badly  the  injections  were  used.  He  refused  to  take 
drugs  in  any  other  way,  and  his  family  doctor  wisely 


38  Morphinism 

directs  his  life  and  diet  so  that  the  necessity  is 
very  sHght. 

These  examples  are  not  common,  but  they  exist, 
and  indicate  to  what  extent  the  fascination  of  the 
needle  may  grow.  There  is  undoubtedly  in  all  such 
persons  a  strongly  marked  neurosis  with  the  addition 
of  hysteria. 

In  the  ordinary  treatment  of  morphin  cases  it  is 
quite  common  for  patients  to  persist  in  the  use  of 
the  needle,  and  to  believe  that  no  good  results  can 
follow  morphin  taken  in  any  other  way.  Often  in 
the  withdrawal  treatment  persons  will  be  found  who 
have  secreted  needles  for  the  ptirpose  of  using  them 
on  themselves  should  occasion  occur. 

A  morphinist  who  had  fully  recovered,  and  had 
not  used  any  of  the  drug  for  two  3'^ears,  carried  about 
with  him  a  needle  and  a  small  bottle  of  morphin  to 
use  in  some  great  emergency.  He  boasted  of  his 
ability  to  abstain  by  showing  the  needle  and  morphin 
which  he  carried.  To  break  up  this  fascinatibn  for 
the  needle  itself  is  often  more  difficult  than  to 
treat  the  drug  addiction. 

Curiously  enough,  the  ill  effects  following  the  use 
of  the  needle,  such  as  pain,  abscesses,  and  inflam- 
mations, do  not  seem  to  have  a  deterrent  effect. 
The  persistency  in  its  use  remains. 

There  seems  to  be  a  very  rapid  increase  in  the 
use  of  morphin  by  the  needle.     Every  year  patients 


The  History  of  Morphinism  39 

suffering  from  this  form  of  addiction  become  more 
numerous.  Often  cocain  is  combined  with  morphin, 
and  frequently  strychnin ;  sometimes  as  high  as  two 
grains  a  day  have  been  injected.  The  combination 
of  cocain  and  morphin  is  always  dangerous. 

In  some  sections  of  the  country  peddlers  carry 
with  them  syringes,  and  for  a  consideration  treat 
persons  who  are  suffering  from  pain  and  distress  by 
injections  of  morphin.  According  to  Dr.  Marks,  of 
St.  Louis,  a  number  of  peripatetic  "doctors,"  so 
called,  travel  about  the  country  prepared  to  give 
relief  to  anybody  who  may  ask  for  it.  These  mor- 
phin peddlers  are  frequently  addicted  to  the  use  of 
the  needle,  and  have  certain  regular  customers 
among  the  lower  classes  who  receive  injections  daily. 
On  the  frontiers,  where  conditions  of  excitement  and 
nerve  strain  react  in  exhaustion,  these  morphin 
dealers  are  in  great  demand. 

Institutions  which  claim  to  be  hospitals  or  sana- 
toriums,  in  many  instances  depend  largely  on  the 
secret  or  open  use  of  this  drug  for  all  forms  of 
diseases  under  their  care.  There  can  be  no  doubt 
that  in  this  way  much  of  the  morphinism  comes 
from  its  surreptitious  use  by  dishonest,  unprinci- 
pled persons.  Careful  study  of  morphinism  shows 
that  not  one-fourth  of  the  cases  have  contracted 
the  addiction  from  curiosity  or  association.  Of  the 
remainder,  a  large  percentage  are  undoubtedly  first 


40  Morphinism 

due  to  its  reckless  use  by  ignorant  and  unskilled 
persons  as  well  as  physicians.  This  is  clearly  evi- 
dent from  the  fact  that  a  large  number  of  phy- 
sicians, and  many  others,  do  not  understand  the 
danger  from  the  use  of  morphin  by  the  needle.  As 
physicians,  they  are  taught  to  prescribe  it  for  transi- 
tory and  other  pains,  with  little  thought  of  any 
possible  dangers  from  its  continuous  use. 

A  number  of  cases  have  been  published  of  tetanus 
following  the  use  of  the  needle  in  morphin-takers. 
While  it  is  evidently  not  a  very  common  occurrence, 
there  is  always  the  possibility  of  it  wherever  the 
needle  is  used  very  freely.  Most  of  the  cases  re- 
ported were  those  of  persons  who  used  the  needle 
without  regard  to  cleanliness,  and  who  were  probably 
predisposed  to  convulsive  states.  Such  cases  appear 
in  persons  where  the  needle  has  been  used  several 
times  along  the  tract  of  the  large  nerves,  followed 
by  abscesses.  In  other  instances  the  use  of  mor- 
phin in  cicatricial  tissue  where  abscesses  have  oc- 
curred before  is  followed  by  tetanus.  The  prog- 
ress of  the  disease  is  rapid,  and  death  follows  in 
a  few  hours  to  a  day  or  so.  The  appearance  of 
of  the  spasms  is  usually  followed  by  increased  doses 
of  morphin,  which  no  doubt  are  very  influential  in 
hastening  the  fatal  issue.  Most  of  the  cases  have 
occurred  in  persons  where  the  injections  were  self- 
administered  and  imder  conditions  of  carelessness. 


The  History  of  Morphinism  41 

In  all  cases  this  form  of  danger  should  be  recognized 
as  jxjssible,  and  great  care  should  be  exercised  to 
prevent  poisoning  by  the  use  of  the  needle. 


CHAPTER  II 

SOME    DISTINCTIONS,    CLASSIFICATIONS,    AND 
STAGES 

The  Term  "Morphinism"  Described.  Morphin:  How  Taken. 
Who  Are  Morphinists?  Who  are  Morphinomaniacsf  TJte  Two 
Classes  and  Their  Relations.  Thought  to  be  a  Moral  Disorder  by 
Many  Persons.  Fascinating  Effects  at  First.  Nervous  Invalids 
Most  Easily  Affected.  Morphin  Hunger.  What  Constitutes 
Morphinism?  Egotism  and  Cunning  in  Explaining  the  Use  of  the 
Drug.  First  Symptoms.  First  Pathologic  Effects.  Predispo- 
sitions, Hereditary  and  Acquired.  Impairment  of  the  Higher 
Brain.  Three  Stages  of  Morphinism:  First,  When  Morphin  is 
Used  for  Some  Specific  Effect;  Second,  Morphin  Used  for  Its 
Mental  and  Physical  Effect;  Third,  Where  Morphin  Cannot  be 
Abandoned  without  Discomfort.  Examples  of  These  Three 
Stages.  Another  Class  Who  Begin  and  Suddenly  Stop  the  Use  of 
Morphin  without  Any  Apparent  Cause.     Examples. 

The  term  "morphinism"  describes  a  condition 
following  the  prolonged  use  of  morphin  either  by  the 
needle  under  the  skin  or  in  solution  by  the  mouth. 

Morphinomania  is  a  term  used  to  designate  the 
condition  of  persons  in  whom  the  impulse  to  use 
morphin  is  of  the  nature  of  a  mania,  possessing  the 
mind  and  dominating  every  thought,  leaving  but 
one  supreme  desire — to  procure  morphin  and  ex- 
perience the  pleasures  it  gives.  Such  a  person  insists 
on  relief  at  once,  and  is  not  contented  with  anything 
less. 

42 


Distinctions,  Classifications,  and  Stages     43 

Usually  morphin  is  taken  by  the  needle,  and,  like 
a  dipsomaniac  among  the  alcoholics,  the  impulse  of 
the  sufferer  to  procure  narcotism  and  rest  is  a  verit- 
able mania.  Such  persons  exhibit  intermittent 
nerve  storms  or  periods  of  great  excitement,  nervous 
discomfort,  and  psychic  pain,  which  may  pass  away 
and  return  again  after  an  interval. 

The  morphinist  is  a  temporizer.  If  he  cannot 
procure  morphin,  he  will  use  spirits  or  any  other 
narcotic  until  he  secures  drug  rest.  Unlike  the 
morphinist,  the  morphinomaniac  will  not  be  satisfied 
with  anything  but  the  one  drug,  and  that  must  be 
had  at  once.  If  he  cannot  procure  morphin,  opium 
in  any  form  will  be  used.  The  morphinomaniac  is 
often  a  psychopath  from  heredity,  with  a  defective 
neurotic  organization,  while  the  morphinist  may 
simply  have  a  poisoned,  exhausted  organism.  The 
morphinomaniac  seldom  uses  cocain,  chloroform,  or 
ether,  but  the  morphinist  turns  readily  to  these 
drugs.  The  morphinist  not  infrequently  becomes 
a  morphinomaniac.  His  former  secretiveness  dis- 
appears, and  delirium  and  delusional  states  appear, 
often  ending  in  insanity  or  in  death  from  acute  inflam- 
mations. 

These  two  classes  are  not  always  marked.  They 
frequently  merge  into  each  other,  making  it  difficult 
to  distinguish  between  them.  When  they  can  be  sepa- 
rated, the  prognosis  and  treatment  are  more  certain. 


44  Morphinism 

These  forms  of  morphinism  are  not  confined  to  one 
class,  but  appear  in  persons  of  all  social  ranks. 
Morphinism  is  often  noted  in  the  prosperous  classes, 
while  morphinomaniacs  are  seen  lower  down,  among 
the  tramps,  criminals,  and  degenerates.  The  latter 
class  appear  frequently  in  public  hospitals  and  dis- 
pensaries, where  their  addiction  is  associated  with 
chronic  diseases.  The  use  of  morphin  is  considered 
by  most  hospital  physicians  as  a  moral  disorder, 
hence  it  is  of  minor  interest  to  them  and  rarely  ex- 
cites much  attention. 

Morphinism  is  one  of  the  most  serious  addictions 
among  active  brain-workers,  professional  and  busi- 
ness men,  teachers,  and  persons  having  large  cares 
and  responsibilities.  There  is  something  very  fas- 
cinating in  the  physiologic  action  of  morphin  which 
enables  the  judge  who  is  nervous  and  confused, 
after  the  use  of  a  single  dose  to  regain  his  former 
clearness  and  self-possession ;  or  for  the  tired  phy- 
sician suffering  from  unsteadiness  and  exhaustion  to 
become  strong  again. 

In  this  way  business  and  professional  men, 
scholars,  teachers,  and  others,  are  able  to  overcome 
difficulties  and  to  go  on  with  more  confidence  and 
clearness  after  the  use  of  morphin  than  before. 
The  large  army  of  invalids  who  suffer  from  nameless 
real  and  imaginary  ills  find  in  it  a  most  pleasing 
nepenthe.     The  idlers  who  suffer  from  ennui  and 


Distinctions,  Classifications,  and  Stages      45 

are  tired  with  the  monotony  of  life  have  a  new  world 
opened  to»them  by  this  drug.  No  wonder  the  de- 
generate, starved,  and  depressed  pauper  turns  to  it 
for  a  solace  which  no  other  drug  can  bring. 

The  relief  and  temporary  narcotism  are  delusive, 
from  the  fact  that  the  latter  produces  a  pathologic 
condition  demanding  a  repetition  of  the  dose  until  the 
disease  impulse  for  more  is  finally  uncontrollable. 
The  morphin  hunger  is  more  persistent  and  difficult 
to  overcome  than  the  desire  for  alcohol,  and  far  worse 
in  its  effect  upon  the  physical  and  mental  organiza- 
tion. The  higher  the  brain  culture  and  develop- 
ment, the  more  certain  and  persistent  are  the  disas- 
trous defects  produced  by  it.  In  all  this  the  con- 
cealed degeneration  makes  it  more  delusive.  The 
early  use  of  morphin,  and  sometimes  its  continued 
use  for  years,  may  exhibit  little  physical  impairment, 
but  in  all  cases  the  will  and  moral  forces  suffer  from 
the  beginning. 

The  question  has  been  asked.  When  can  you 
properly  designate  a  patient  as  a  morphinist?  The 
answer  is,  Whenever  this  drug  is  used  regularly  for 
any  purpose  whatever,  the  person  is  a  morphinist. 
The  gourmand,  or  one  who  suffers  from  indigestion 
and  obtains  relief  by  this  means,  or  one  who  has 
insomnia  or  neuralgic  pains  and  uses  this  drug,  is  a 
morphinist. 

In  a  certain  number  of  cases  morphin  is  used  with- 


46  Morphinism 

out  any  special  reasons,  and  with  apparent  uncon- 
sciousness of  the  dangerous  consequences.  This  con- 
dition, in  which  the  person  acts  automatically  and 
without  motive  or  purpose,  has  been  called  psychic 
paralysis.  Such  persons  show  great  ingenuity  in  ex- 
plaining their  motive  for  its  use,  ascribing  it  to  the 
most  absurd  reasons ;  and  when  the  danger  is  pointed 
out,  are  strangely  egotistical  in  the  assertion  of  their 
strength  and  power  of  self-control.  This  egotism 
grows  with  the  years,  and  is  always  a  veritable 
delusion.  In  such  cases  there  is  an  opinion  that 
the  use  of  the  drug  is  always  outside  the  danger-line, 
and  can  be  checked  any  time.  But  actually  no 
known  dividing-line  exists  between  the  use  and 
abuse  of  morphin.  While  it  may  be  taken  medicin- 
ally for  temporary  effects,  and  abandoned  again, 
there  is  always  a  certainty  that  the  giving-up  of 
the  morphin  after  continued  use  will  become  difficult, 
and  perhaps  impossible.  Each  narcotism  or  sleep 
from  morphin  increases  this  peril. 

While  all  persons  who  use  morphin  do  not  become 
chronic  or  habitual  users,  the  number  is  so  large 
and  the  desire  increases  so  rapidly  that  those  who  es- 
cape are  the  exceptions  to  the  rule.  The  early  relief 
which  morphin  brings  to  the  neurotic  sufferer  is 
often  the  beginning  of  an  unknown  journey,  ending 
in  disease  and  death. 

To  limit  the  term  morphinism  only  to  persons 


Distinctions,  Classifications,  and  Stages      47 

who  use  the  drug  constantly  is  to  ignore  a  long 
preliminary  stage  in  which  the  disease  existed  as 
certainly  as  in  the  later  stages.  A  large  proportion 
of  this  class  have  found  the  first  use  of  morphin 
pleasing,  and  its  first  narcotism  was  followed  by 
no  unpleasant  symptoms.  While  morphin  is  always 
a  narcotic,  its  first  effect  in  many  cases  is  that  of  a 
stimulant,  and  later,  after  the  narcotic  effect  has 
passed  off,  irritation  and  nausea  follow.  Still  later, 
headache  and  general  depression  of  uncertain  dura- 
tion come  on. 

In  many  cases  the  first  use  of  morphin  is  followed 
by  great  depression,  with  disturbance  of  the  stom- 
ach and  general  irritation.  These  unpleasant  effects 
often  are  easily  overcome,  and  with  repeated  doses 
grow  less  and  less  and  then  disappear  altogether. 

Some  morphin-takers  have  digestive  disturbances 
from  the  start,  and  never  fully  recover  from  the 
irritation  which  seems  to  be  associated  with  the 
narcotism.  These  poisonous  effects  are  fortunately 
so  pronounced  in  many  cases  that  the  drug  is  not  con- 
tinued, although  other  drugs  may  be  combined  with 
it  to  remove  these  unpleasant  symptoms.  Morphin 
by  the  needle  does  not  affect  the  stomach,  hence 
its  use  is  more  popular. 

Where  morphin  acts  as  a  pleasing  sedative  from 
the  start,  there  is  undoubtedly  some  peculiarity  in 
the  constitution  favoring  its  use.     Where  it  acts  as 


48  Morphinism 

an  irritant  and  stimulant,  some  repelling  power  ex- 
ists, which  may  be  finally  overcome  by  the  con- 
tinuance of  the  drug.  The  fact  of  early  sensitive- 
ness to  its  use  is  very  important  in  the  study  and 
treatment. 

If  the  early  use  of  morphin  as  a  medicine  produces 
poison  symptoms,  such  as  irritation,  depression,  and 
nausea,  then  irregular  and  pronounced  narcotism,  its 
physiologic  effect  is  serious.  If,  on  the  other  hand, 
its  effect  is  that  of  narcotism,  with  slight  exhilara- 
tion and  pleasing  anesthesia  of  the  higher  brain- 
centers,  the  possibility  of  its  addiction  and  of 
morphin  disease  is  very  great.  In  the  first  case 
serious  organic  changes  associated  with  other  dis- 
eases will  soon  develop  if  morphin  is  used;  while  in 
the  latter  case  the  morphin  may  be  continued  for  a 
long  time  without  pronounced  changes. 

Any  person  who  experiences  relief  from  pain  and 
discomfort  by  the  use  of  morphin  has  received  a 
pathologic  impression,  the  intensity  and  permanency 
of  which  will  depend  on  the  strength  and  sensitiveness 
of  the  organism.  If  he  has  no  inherited  predis- 
position to  seek  relief  from  every  pain  and  discom- 
fort, and  is  not  a  neurotic  by  inheritance  or  errors  of 
living,  the  impression  will  be  less  marked  and  soon 
effaced ;  but  if  he  has  a  neurotic  tendency,  or  a  crav- 
ing for  relief  from  pain  or  discomfort,  or  suffers  from 
nervous  exhaustion,  defective  niitrition,  and  con- 


Distinctions,  Classifications,  and  Stages     49 

trol,  the  impression  will  be  more  or  less  permanent, 
and  the  effects  will  not  wear  off  at  once.  The  repe- 
tition of  the  drug  will  constantly  widen  and  deepen 
these  pathologic  defects.  When  the  intervals  be- 
tween the  use  of  the  drug  grow  less  and  less,  the 
changes  will  increase  and  intensify  into  a  morbid 
craving.  This  is  an  indication  of  serious  impairment 
both  of  the  nutrition  and  control-centers  of  the 
brain. 

The  narcotism  of  morphin  is  a  temporary  suspen- 
sion of  brain  forces,  with  defects  of  cell  and  nerve 
energy ;  degeneration  and  changes  of  both  functional 
and  organic  activity  follow.  Morphinism  is  a  form 
of  insanity,  and  the  use  of  the  drug  leads  slowly  or 
rapidly  to  disease  of  both  the  brain  and  nervous 
system.  The  constant  narcotism  of  the  higher 
brain-centers  soon  impairs  their  integrity  and  de- 
stroys their  normal  condition.  When  the  craving 
for  morphin  becomes  serious  and  imperative  from 
the  withdrawal,  the  indications  are  unmistakable 
of  serious  and  possibly  permanent  impairment. 

In  a  very  large  number  of  cases  morphinism  may 
be  divided  into  three  stages.  While  these  stages 
are  not  always  distinct  and  well  marked,  it  is  well  to 
observe  and  to  recognize  these  distinctions,  which 
enable  the  physician  to  more  carefully  study  the 
prognosis  and  treatment. 

The  first  stage  is  that  in  which  the  drug  is  taken 
4 


50  Morphinism 

for  some  specific  purpose,  such  as  colic,  spasmodic 
pain,  fluxes,  and  irritating  states  of  the  nervous 
system.  The  effects  of  the  drug  are  often  satis- 
factory, and  the  relief  which  follows  is  complete, 
with  no  unpleasant  after-effects.  The  recurrence  of 
these  or  of  similar  conditions  at  intervals  is  followed 
by  the  same  pleasing  results.  Both  the  physician 
and  the  patient  realize  that  morphin  is  a  valuable 
remedy.  Later,  when  any  other  discomforts  or  pains 
arise,  the  person  turns  to  this  source  for  relief. 

It  is  but  a  step  from  its  use  for  relief  of  physical 
pain  to  that  for  mental  and  psychic  troubles.  In 
insomnia  its  effects  are  often  very  pleasant;  also  in 
care  and  distress  from  worry  and  general  exhaustion. 
In  addition  to  this,  there  are  states  of  mental  exalta- 
tion and  general  physical  satisfaction  following  its 
use.  This  is  the  first  stage,  and  may  last  from  a 
few  weeks  to  several  years,  during  which  morphin 
may  be  considered  only  as  an  excellent  remedy  to 
be  taken  for  pain  and  suffering,  and  never  in  more 
than  one  or  two  doses  at  a  time.  The  thought  of  its 
use  becoming  an  addiction  and  dependence  upon  it 
is  not  considered. 

During  this  stage  a  positive  conviction  has  been 
formed  in  the  mind  of  the  value,  power,  and  useful- 
ness of  the  drug  as  a  remedy. 

The  second  stage  begins  at  a  point  where  morphin 
is  used  for  days  and  weeks  for  some  specific  physical 


Distinctions,  Classifications,  and  Stages      51 

derangement;  then  for  imaginary  pains,  with  the 
same  satisfactory  results.  Later  the  increasing  de- 
pendence upon  this  drug  for  the  relief  of  all  forms 
of  suffering  and  pain  leads  to  its  continued  use, 
until  its  abandonment  becomes  difficult  and  painful, 
and  often  causes  much  discomfort  and  distress.  The 
mind  during  this  second  stage  becomes  profoundly 
convinced  of  its  value.  Even  when  the  effort  to 
discontinue  it  is  followed  by  suffering,  the  impres- 
sions of  its  value  still  remain. 

Then  comes  the  third  stage,  in  which  morphin  is 
used  continuously  and  the  attempt  to  give  it  up  is 
abandoned  because  it  is  accompanied  by  so  much 
discomfort  and  suffering.  The  second  stage,  like 
the  first,  may  extend  over  a  long  period,  but  the 
third  stage  is  unlimited  except  by  treatment. 

The  belief  of  the  patient  in  his  ability  to  stop  at  will 
in  the  first  and  second  stages,  although  continuing  to 
the  third,  is  somewhat  shaken,  and  at  times  greatly 
doubted.  The  first  stage  is  very  common,  and  possi- 
bly might  continue  a  lifetime,  never  changing  into  the 
second  or  third.  In  some  instances  morphin  given  in 
a  dose  beyond  a  certain  point  is  followed  by  nausea 
and  repulsion,  and  up  to  a  certain  stage  smaller 
doses  are  followed  by  pleasant  relief.  The  second 
stage  is  absent  in  many  cases. 

Morphin  as  a  common  remedy,  taken  for  pains  and 
aches,  may  suddenly,  from  some  unknown  cause, 


52  Morphinism 

develop  into  an(mcurable  craze  for  its  continuous 
use.  Disease,  injury,  mental  and  physical  shocks, 
are  frequently  followed  by  a  sudden  impetuous 
demand  for  morphin,  and  the  patient  will  become  a 
morphinist.  Often  in  the  early  treatment  of  these 
maladies,  alcohol,  chloral,  chloroform,  or  any  of  the 
common  narcotics  may  take  its  place  as  a  remedy 
with  equal  efficacy. 

The  second  stage  is  practically  the  development 
of  the  disease  where  morphin  is  taken  for  days  and 
weeks,  then  abandoned  for  some  other  drug  or  taken 
up  again  according  to  circumstances  and  condi- 
tions. Often  morphin  is  used  to  relieve  some  con- 
dition of  disease,  and  when  taken  for  three  or  four 
weeks  at  a  time,  is  abandoned  with  difficulty. 
Hence  it  is  always  a  source  of  danger  to  use  morphin 
for  any  length  of  time  in  neurotic  cases,  or  to  resort 
to  it  for  temporary  pains  and  discomforts. 

The  morphinomaniac  who  continually  craves  the 
drug  has  already  passed  the  first  and  second  stages 
of  the  disease.  Usually  morphin  is  taken  at  first 
for  several  days  or  weeks  in  small  doses;  then, 
after  one  or  two  attempts  to  abandon  it,  a  mania 
develops  for  its  continuous  use. 

The  morphinist  has  usually  had  a  long  first  stage 
of  occasional  use  with  long  free  intervals,  taking  it 
only  on  one  or  two  occasions,  then  dropping  it; 
finally  using  it  at  shorter  intervals  and  for  longer 


Distinctions,  Classifications,  and  Stages      53 

times,  until  it  becomes  necessary  to  his  comfort. 
Efforts  to  abandon  it  are  temporarily  successful,  but 
relapses  frequently  occur. 

The  following  cases  are  types  of  these  classes,  and 
are  not  uncommon: 

Example  i. — An  active  business  man  first  found 
relief  from  obstinate  toothache  by  the  use  of  mor- 
phin.  Later  he  suffered  from  an  injury  which  was 
painful,  and  by  the  advice  and  consent  of  the 
physician  used  morphin  for  two  or  three  days,  and 
recovered.  A  year  later  for  an  attack  of  the 
grip  morphin  was  found  to  be  effectual.  Some 
time  afterward  he  used  morphin  pills  for  an  attack 
of  colic.  From  this  time  morphin  was  a  household 
remedy,  used  in  every  condition  of  pain  and  suffer- 
ing. It  was  used  for  indigestion,  neuralgias,  colds, 
and  other  minor  affections,  several  days  at  a  time. 
Finally  he  used  it  several  months  for  intermittent 
fever,  and  found  it  very  difficult  to  give  up.  Later 
still,  he  claimed  to  have  insomnia,  for  which  morphin 
was  given,  and  all  attempts  to  abandon  the  drug 
increased  the  desire,  and  so  he  became  a  morphinist. 

Example  2. — A  business  man  who  had  for  several 
years  taken  morphin  pills  at  intervals  for  functional 
and  other  disturbances  suddenly  lost  all  his  property. 
He  was  overwhelmed  with  grief  and  sorrow,  and 
always  went  to  bed  stiffering  from  depression,  mel- 
ancholia,  and  general  debility.     Suddenly  he  de- 


54  Morphinism 

veloped  a  mania  for  morphin,  and  for  several  weeks 
was  in  a  state  of  continuous  narcosis.  The  mania 
subsided,  but  he  could  not  abandon  the  use  of  the 
drug.  He  was  placed  in  an  asylum  and  the  drug 
was  withdrawn,  but  he  relapsed  the  moment  he  re- 
gained his  liberty,  and  seemed  possessed  with  the 
desire  to  use  morphin  at  all  times  and  under  all 
circumstances.  There  were  but  two  stages  in  this 
case.     The  last  was  morphinomania. 

Example  3, — ^A  woman  in  middle  life,  previously 
healthy,  began  to  use  morphin  in  moderation  at 
the  change  of  life.  She  has  for  the  last  ten  years 
been  using  it  at  short  intervals,  giving  it  up  readily 
without  any  particular  pain  or  suffering.  Then,  for 
reasons  real  or  imaginary,  resuming  it  again,  using 
from  two  to  four  grains  a  day.  She  became  alarmed 
at  the  idea  of  becoming  a  morphinist  and  diminished 
the  dose  until  it  was  finally  given  up  altogether. 
The  probabilities  are  that  in  the  near  future  she  will 
resume  it,  and  be  unable  to  give  it  up,  and  thus 
become  permanently  addicted. 

These  three  examples  indicate  a  large  class  of 
morphin-takers  and  their  general  history  and  pro- 
gress. There  is  still  another  class,  which  are 
anomalies,  but  nevertheless  are  found  in  suffi- 
cient numbers  to  attract  attention.  They  are  per- 
sons who,  after  the  morphin  addiction  of  several 
years,  suddenly  become  abstainers,  giving  credit  for 


Distinctions,  Classifications,  and  Stages     55 

their  abstinence  to  the  most  insignificant  cause,  or 
boasting  of  the  power  of  their  will,  which  enabled 
them  to  stop.  These  persons  make  astonishing 
recoveries  and  seem  to  be  exceptions  to  all  rules 
and  methods  of  treatment.  In  some  instances 
powerful  mental  impressions  are  no  doubt  active  as 
causes,  driving  out  the  morphin  impulse  and  super- 
seding it  by  some  other  dominant  idea.  In  others 
the  force  of  circumstances  seems  to  be  powerful 
enough  to  break  up  the  morphin  addiction. 

An  example  of  this  class  was  that  of  a  woman 
taking  six  grains  of  morphin  daily,  who  became  con- 
vinced that  this  addiction  was  an  unpardonable  sin. 
She  went  to  bed  and  remained  there  for  a  week 
without  drugs  or  treatment,  and  fully  recovered. 

In  a  second  case  a  man  taking  five  grains  of 
morphin  daily  received  a  letter  from  a  woman  who 
had  rejected  his  addresses  some  years  before  offering 
to  marry  him  on  a  certain  specified  date.  He 
abandoned  the  drug  at  once,  and  after  lying  in  bed 
two  days  went  about  restored,  was  married,  and  did 
not  use  the  drug  for  at  least  two  years  after.  No 
further  history  was  obtained. 

A  third  example  was  that  of  a  very  miserly  man 
who  had  used  morphin  for  several  years.  He  was 
convinced  by  his  wife  of  the  great  expense  of  the 
drug  and  the  peril  to  his  property,  and  without  any 
discomfort  he  gave  it  up  and  went  about  apparently 
as  if  it  were  no  deprivation. 


CHAPTER    III 
ETIOLOGY;    INJURIES;    SHOCKS;    ETC. 

Study  of  the  Causes  Reveals  Only  Physical  Forces.  Border-land 
Neuroses.  Uniform  Causation.  Progress  and  Development. 
Only  a  Few  of  the  Causes  and  Laws  Which  Govern  Them  are  Known. 
First  Group  are  the  Neuroses  from  Inheritance.  Diathesis  Coming 
from  Alcoholic,  Syphilitic,  Tuberculotic,  and  Hysterical  Ancestors. 
Varieties  and  Conditions.  One  Class  Use  Morphin  for  Exhaus- 
tion; Another,  for  the  Pain  from  Injury  and  Disease.  Children 
Show  These  Defects.  Morphinism  a  Psychosis  Both  Inherited  and 
Acquired.  Mental  Defects  and  Characteristics.  Atavism,  Pre- 
cocity, and  Menial  Instability  Prominent.  Other  Causes  are  Star- 
vation, Intoxication,  Brain-strains,  and  Nervous  Drains.  Mor- 
phin Unpleasant  at  First.  Morphinism  from  Injury.  Examples. 
Autointoxications  Often  Causes.  Surgical  Operations.  Injuries 
to  the  Cord.  Etherization  Predisposes  to  Use  of  Morphin.  Dan- 
ger from  Morphin  in  Gynecologic  Practice.  Shock  and  Excitement 
Causes.     Association  with  Alcohol. 

All  study  of  the  etiology  of  morphinism  should 
be  made  from  a  physical  standpoint.  No  study  of 
moral  causes  should  be  considered  by  the  physician, 
for  the  reason  that  science  has  failed  to  point  out 
dividing-Hnes  and  to  indicate  where  so-called  vice 
and  disease  join.  The  present  knowledge  of  the 
physiology  and  psychology  of  the  brain  has  indicated 
no  causes  other  than  physical  in  the  development  of 
morphinism. 

The  assumption  that  many  of  these  border-land 

56 


Etiology;  Injuries;  Shocks;  Etc.  57 

neuroses  begin  by  a  wilful  act  is  not  sustained  by 
any  test  of  examination.  Exact  studies  of  the 
history  and  conditions  of  life  and  living  which  have 
preceded  morphinism  point  out  a  distinct  series  of 
causes  which  are  more  or  less  exact  and  uniform  in 
their  progress  and  development.  It  is  no  accident 
or  fortuitous  combination  of  events  which  has  de- 
veloped the  morphinist.  The  causes  and  conditions 
are  as  certain  and  fixed  as  those  which  govern  the 
growth  of  a  tree  or  the  building-up  of  a  plant.  While 
it  is  not  always  possible  to  trace  all  of  these  condi- 
tions, we  can  see  outlines  which  indicate  their  general 
trend,  and  thus  be  confident  that  further  studies 
will  clear  up  many  of  the  mysteries  of  the  disease. 

Researches  along  this  line  are  full  of  promise  in 
indicating  the  operation  of  forces  which,  when 
known,  can  be  changed  or  prevented.  At  present 
we  can  only  point  out  some  general  facts  and  leave 
the  wide  ranges  of  the  unknown  to  further  study 
in  the  future.  When  a  clinical  study  is  made  of  a 
large  number  of  these  cases,  they  divide  into  certain 
groups. 

The  first  of  these  groups  may  be  termed  the 
neurotics  from  inheritance.  They  are  persons  who 
have  received  from  their  parents  certain  defects  of  the 
brain  and  nervous  system;  also  certain  predisposi- 
tions and  tendencies  which  have  culminated  in 
morphinism.     These  inherited  faults  are  most  fre- 


58  Morphinism 

quently  hypersensitiveness  of  the  brain-centers  with 
low  resisting  powers,  indisposition  and  feebleness, 
and  unwillingness  to  bear  pain  or  suffering.  Asso- 
ciated with  this  are  imperative  psychic  degenerative 
tendencies  to  seek  physical  pleasure  and  to  avoid 
all  pain  and  discomfort.  Often  the  central  object 
in  life  is  the  gratification  of  every  pleasurable  im- 
pulse. The  brain  is  dominated  by  these  lower  im- 
pulses, and  no  reasoning  of  future  good  can  overcome 
the  desire  for  present  gratification. 

Such  persons  inherit  from  their  ancestors  physical 
defects  of  body,  lack  of  mental  and  muscular  strength, 
disturbed  nutritive  functions,  and  many  unknown 
conditions  and  tendencies  to  early  exhaustion  and 
disease.  Often  these  neurotic  tendencies  are  con- 
cealed. Externally,  the  person  seems  normal  and 
well,  fully  equal  to  the  average;  but  test  and  ex- 
perience show  irregularities  of  control,  defective 
reasoning,  feeble  powers  of  restoration,  and  inability 
to  bear  the  ordinary  strains  and  drains  of  life. 
Defects  of  morals,  defects  of  character,  and  defects 
of  judgment  are  seen  when  exposed  to  any  stress  or 
temptation. 

In  a  study  of  the  morphinists  who  belong  to  this 
class,  the  question  is  sometimes  difficult  to  determine 
how  far  these  radical  impairments  have  originated 
or  are  transmitted  through  the  use  of  the  drug.  This 
inquiry  leads  one  back  to  the  character  and  habits 


Etiology  ;  Injuries  ;  Shocks  ;  Etc.  59 

of  the  ancestors  and  the  diseases  from  which  they 
suffered.  Here  the  facts  are  so  numerous  and  com- 
plex that  it  is  difficult  to  classify  them,  or  to  do 
more  than  to  study  them  in  a  general  way. 

What  has  probably  been  transmitted  is  a  neurotic 
diathesis  or  a  special  tendency  to  exhaustion  from 
the  slightest  exciting  causes.  The  vigor,  power  of 
endurance,  and  capacity  of  resistance  are  all  below 
par.  Along  with  this  in  many  cases  is  a  direct  pre- 
disposition to  find  relief  by  external  remedies,  of 
which  morphin  and  other  narcotics  are  the  most 
common  means.  This  neurotic  diathesis  follows  very 
largely  from  alcoholic,  syphilitic,  tuberculous,  hys- 
terical, and  neurotic  ancestors. 

The  first  of  these  classes  are  actually  poisoned  cases 
who  transmit  defective  cell  and  nerve  energy  to 
their  descendants  with  greater  certainty  than  that 
of  any  other  quality.  The  tuberculous,  hysterical, 
neurotic,  and  others  of  this  class  are  always  fol- 
lowed by  degenerate  offspring. 

A  great  variety  of  conditions  may  neutralize, 
change,  or  divert  the  current  of  defects;  or,  for 
some  unknown  reason,  these  defects  may  be  held  in 
abeyance  and  lie  dormant  for  a  generation,  and 
will  then  reappear.  An  entire  generation  from  de- 
fective ancestors  sometimes  will  not  exhibit  these 
tendencies,  although  when  subjected  to  certain  ex- 
citing causes  they  are  roused  into  activity. 


6o  Morphinism 

Probably  one  of  the  most  prominent  classes  of 
ancestral  defects  which  develop  morphinism  in  the 
second  generation  is  that  of  physical  and  nervous 
exhaustion.  Parents  who  are  worn  out  mentally 
and  physically  are  examples.  Thus,'  hard-working 
physicians,  clergymen,  active  business  men,  law- 
yers, teachers,  and  others  who  have  been  engrossed 
in  their  business,  and  early  become  neurasthenic  and 
cerebrasthenic,  are  frequently  followed  by  children 
who  become  morphin-takers. 

Another  class,  who  have  been  idlers,  gourmands, 
and  pleasure-seekers,  whose  whole  life  has  been  a 
round  of  physical  and  sensual  indulgences,  dying 
early  from  some  acute  disease,  are  often  followed 
by  descendants  who  have  the  same  neurotic  ten- 
dencies and  who  seek  relief  in  morphin. 

A  third  class  are  invalids  of  th^  neurotic  type  who 
have  suffered  from  injury  to  the  nerve-centers, 
nutritional  disorders,  and  local  inflammations,  and 
have  children  who  early  become  morphin-takers. 
Many  obscure  histories  of  morphinists  have  been 
published,  traceable  to  such  ancestry,  but  there 
has  been  no  special  study  of  them. 

Although  disputed  by  some  authorities,  the  ques- 
tion is  practically  settled  that  morphinists  transmit 
their  tendencies  to  their  children.  This  is  established 
from  the  records  of  many  cases.  The  following  is  a 
good  example: 


Etiology;  Injuries;  Shocks;  Etc.  6i 

An  alcoholic  father  arid  a  morphinist  mother  had 
five  children.  Soon  after  birth  every  child  ex- 
hibited an  extraordinary  degree  of  irritation,  rest- 
lessness, and  continual  crying.  These  were  only 
quieted  by  opium.  Three  of  these  children  died 
in  infancy.  The  other  two  were  given  opium  at 
intervals  through  childhood,  and  after  puberty 
became  drug-takers,  one  of  them  dying  soon  after- 
ward; the  other  is  choreic  and  hysteiic. 

Dr.  Happel,  of  Trenton,  Tenn.,  reports*  several 
children  born  of  morphinist  mothers,  who  had 
defects  of  the  heart,  non-closure  of  the  ductus 
arteriosus  and  foramen  ovale,  and  a  deficiency  of 
the  ventricular  septum.  These  children  were  born 
cyanotic  and  early  suffered  from  colic,  were  rest- 
less and  fretful,  and  when  given  opium  were 
relieved.  He  says:  "My  experience  thoroughly 
satisfies  me  that  when  the  mother  uses  morphin 
habitually,  the  child  is  born  with  some  defect  of 
the  heart,  a  congenital  heart  disease ;  either  there  is 
non-closure  of  the  ductus  arteriosus,  or  the  foramen 
ovale,  and  in  some  cases  the  interventricular  septum, 
is  deficient,  I  do  not  pretend  to  assert  that  the  use 
of  morphin  is  the  sole  cause  of  these  defects,  but 
that  when  morphin  is  used  to  excess,  in  the  large 
majority  of  cases  the  deficiencies  do  exist. 

"Generilly  the  first  intimation  that  you  have  of 

*  "Journal  of  Inebriety,"  July,  1895. 


62  Morphinism 

any  defect  in  the  development  of  the  child  is  that, 
after  becoming  restless  and  fretful,  a  cyanotic  con- 
dition supervenes.  The  nurse  calls  your  attention 
to  the  fact  that  the  child  is  'blue.'  The  child  may 
have  been,  and  frequently  is,  bom,  as  shown  in  the 
few  histories  given,  apparently  in  fine  condition.  It 
rests  well  for  the  first  twelve  or  twenty-four  hours. 
It  is  reported  to  you  as  an  unusually  'good  child,' 
sleeps  nearly  all  the  time,  does  not  want  to  be 
nursed,  etc.  On  the  second  day,  however,  you  are 
apt  to  be  informed  that  the  child  is  fretful,  restless, 
colicky,  and  then,  later  on,  that  day  or  the  next, 
that  the  child  becomes  blue  at  times.  As  a  rule,  this 
condition  grows  worse  unless  you  suspect,  or  know, 
the  cause  of  the  trouble  and  begin  the  free  use  of 
opiates  and  stimulants.  This  condition  is  easily 
understood,  and  the  need  of  the  treatment  suggested 
comprehended,  if  you  bear  in  mind  the  fact  that  the 
child  is  bom  an  opium-user.  Its  blood  is,  so  to 
express  it,  saturated  with  the  drug.  The  mother 
has  lived  on  it,  and  the  fetus  has  developed  under 
all  its  baneful  influences.  To  finish  up  and  perfect 
the  heart  is  the  last  work  to  be  done,  and  the 
closure  of  the  foramen  ovale  and  other  portions 
of  the  heart  being  left  to  be  finished  after  the 
child  has  begun  its  separate  existence,  the  supply 
of  opiates  being  suddenly  cut  off,  the  equilibrium  of 
the  nervous  system  is  destroyed  and  nature's  finish- 


Etiology  ;  Injuries  ;  Shocks  ;  Etc.  63 

ing  work  suspended.  The  closure  of  the  foramen 
ovale  could  not  be  permitted  as  long  as  the  child 
existed  in  utero,  and  now  the  work  cannot  be  carried 
on,  with  the  nervous  system  crying  out  for  opium; 
hence  the  restlessness  which  induces  irregularities 
of  circulation,  blueness,  etc.  If  this  cry  of  the  ner- 
vous system  can  be  quieted  and  the  child  nourished, 
nature  may  be,  and  sometimes  is,  able  to  complete 
her  work.  .  .  .  Morphin  becomes,  'me  judice,' 
a  disease  transmissible  by  heredity  almost  to  as  great 
a  degree  as,  and  in  the  same  way  that,  tuberculosis 
and  such-like  diseases  are  handed  down.  Not  that 
the  disease  is  itself  transmitted,  but  a  condition,  a 
soil,  a  nidus,  or  whatever  you  may  be  pleased  to 
call  it,  is  handed  down  to  the  child,  and  some  for- 
tuitous circumstance  develops  the  disease.  The 
offspring  of  the  victim  to  the  morphin  habit  has  a 
condition  of  the  nervous  system  that  when  once 
subjected  to  some  exciting  cause  develops  the  habit 
rapidly." 

Other  authors  have  mentioned  morphinist  chil- 
dren whose  mothers  used  opium  during  the  period  of 
pregnancy.  An  example  of  this  kind,  although  con- 
cealed, is  illustrated  in  the  following:  A  strong- 
minded,  neurotic  woman  had  five  children,  each  one 
of  which  had  a  period  of  excessive  irritability  and 
sensitiveness  during  childhood,  and  grew  up  neu- 
rotic, choreic,  and  suffered  from  other  nerve  defects. 


64  Morphinism 

Later  it  was  ascertained  that  the  mother  had  used 
morphin  secretly  during  the  time  of  pregnancy  with 
each  child;  then,  after  the  period  of  lactation,  gave 
up  the  drug.  At  the  birth  of  the  last  child  she  could 
not  give  it  up,  and  so  continued  it  openly  until  her 
death. 

An  instance  of  the  opium-taking  of  a  father  ap- 
pearing in  morphinism  in  the  child  bears  on  this 
point.  A  soldier  who  received  in  the  Civil  War 
some  wound  of  the  nerves  of  the  arm  became  an 
opium-taker.  He  married  and  had  two  children. 
His  addiction  was  unknown  and  concealed  until  his 
death.  Both  children  became  morphin-takers  in 
early  life.  The  daughter  found  morphin  most  fas- 
cinating soon  after  her  first  pregnancy.  The  son 
drank  spirits,  and  then  turned  to  morphin.  Both 
children  are  now  using  the  drug  regularly. 

It  is  impossible  at  present  always  to  trace  these 
transmitted  defects,  which  seem  to  move  in  such  end- 
less complex  procession ;  but  it  is  certain  that  mor- 
phinism and  opium-taking  in  the  parents  are  followed 
in  the  children  by  positive  predispositions  and  in- 
herited tendencies  to  use  the  same  drug.  Whether 
the  children  become  morphinists  or  use  some  other 
drug,  there  are  innumerable  evidences  among  them 
of  imperfect  growth,  defective  nutrition,  and  a  ten- 
dency to  irregular  habits  and  modes  of  life  and  faulty 
reasonings  that  are  only  controlled  or  cured  in  a 


Etiology ;  Injuries  ;  Shocks ;  Etc.  65 

few  exceptional  cases.  The  use  of  morphin  has  per- 
manently impressed  the  cellular  and  nervous  sys- 
tems, so  that  it  is  almost  impossible  to  transmit  a 
normal  organism  from  such  ancestors. 

Children  of  alcoholics,  or  of  persons  who  use  spirits 
moderately  at  meals,  who  pride  themselves  on  their 
temperate  use  of  spirits,  are  often  very  much  aston- 
ished to  find  their  children  utterly  devoid  of  power 
of  control  and  of  capacity  to  follow  their  parents  in 
moderate  drinking,  while,  on  the  contrary,  they  some- 
times show  morbid  predispositions  and  incapacities  of 
reason  and  control  which  very  soon  find  relief  in 
the  use  of  morphin.  Here  the  poison  of  alcohol, 
impairing  and  perverting  the  cell  function  and 
growth,  lessens  the  capacity  to  bear  pain  and  dis- 
comfort in  the  children. 

Often  these  inherited  neurotic  disturbances  are 
concealed,  and  do  not  appear  prominently  in  every 
member  of  the  family.  Sometimes  they  pass  on  to 
the  second  generation ;  then,  from  some  change  fol- 
lowing the  strains  of  life,  develop  into  other  forms  of 
nervous  disease,  of  which  morphinism  is  very  com- 
mon. The  same  causes  which  produced  marked 
deterioration  in  the  parents  are  often  concentrated 
in  the  child,  and  more  pronounced  and  almost  irre- 
sistible. Such  subjects  become  invalids  early  in  life, 
suffering  from  defects  of  nutrition  and  toxic  changes 
of  the  blood  from  the  slightest  cause. 
5 


66  Morphinism 

Many  of  these  cases  appear  to  break  down  through 
changes  of  the  circulatory  system  and  acute  degen- 
erative conditions  of  the  body.  The  ordinary  stress 
and  strain  of  Hfe  falls  most  heavily  on  the  metabolic 
activities.  Others  with  these  predispositions  show 
nervous  failures,  with  low  vitality  and  constant 
physiologic  crises,  and  seek  relief  from  any  source. 

It  is  now  a  well-recognized  fact  that  the  trans- 
mission of  the  defects  of  the  parents,  in  predisposi- 
tions to  the  children,  is  a  very  active  cause  in  nearly 
all  functional  and  organic  diseases  of  the  nervous 
system.  Eminent  authorities  agree  that  a  large 
proportion  of  all  cases  of  inebriety,  border-land  in- 
sanities, paranoiacs,  hysterics,  inebriates,  and  dipso- 
maniacs, is  due  in  a  large  measure  to  heredity. 
Morphinism  is  one  of  these  psychoses.  It  comes 
from  the  same  source  and  follows  parallel  lines  of 
failure  and  decay.  Parents,  in  these  classes,  are  usu- 
ally nerve-exhausted,  neurotic  persons,  often  over- 
worked mentally  and  physically,  and  living  under 
conditions  of  great  mental  and  physical  strain  with 
defective  environments.  Often  they  are  spirit-  and 
drug- takers,  and  are  frequently  classed  as  paranoiacs, 
psychopaths,  who  live  on  the  borders  of  insanity. 
Frequently  they  belong  to  the  class  of  mental,  moral, 
and  physical  bankrupts  who  are  merely  staying  in 
the  world,  with  little  vital  interest  in  its  affairs. 
Children  from  such  ancestry  have  often  unusual  sus- 


Etiology  ;  Injuries ;  Shocks  ;  Etc.  d'j 

ceptibility  to  pain,  and  are  rapidly  exhausted  and 
depressed,  always  seeking  relief  and  rest,  the  mind 
being  in  a  continual  hyperesthetic  or  anesthetic 
state. 

Some  representatives  of  this  class  are  the  nomadic 
tramps,  restless,  uneasy,  always  moving;  or,  in  other 
circles,  the  wealthy  idler,  the  globe-trotter,  who  is 
ever  changing  from  place  to  place,  never  satisfied, 
but  always  looking  and  striving  for  something  new 
and  different.  They  soon  become  drug-takers, 
spirit-takers,  and  when  morphin  is  found  agreeable 
seldom  abandon  it.  Fortunately,  opium  and  its 
alkaloids  are  often  repelling  at  first,  and  many  neu- 
rotics of  this  class  are  far  too  weak  to  persevere  in 
the  use  of  any  narcotic  or  drug  for  relief  if  it  pro- 
duces discomfort  at  the  start.  When  spirits  or 
drugs  are  taken,  if  the  environment  and  conditions 
of  life  make  the  effects  of  the  drug  unpleasant,  it  is 
abandoned;  but  if  the  conditions  and  environment 
are  favorable,  the  use  of  the  drug  is  continued. 

Many  morphinists  are  seen  among  the  intellectual 
class  of  persons,  who  have  superior  intellects,  but  lack 
endurance  and  continuity  of  purpose.  Often  such 
persons  in  early  life  are  precocious,  and  are  pushed 
forward  by  their  parents  until  they  become  nervous 
bankrupts,  and  fall  back  upon  spirits  and  drugs  for 
relief  from  exhaustion.  Such  children  are  practi- 
cally switched  on  the  side-track  to  dissolution  by 


68  Morphinism 

their  parents.  No  matter  what  their  education, 
surroundings,  or  occupation  may  be,  they  are  de- 
fectives, and  are  seldom  able  to  pass  through  life 
successfully.  Should  opium,  spirits,  or  morphin  be 
given,  some  inherited  predisposition  will  be  awak- 
ened which  soon  grows  beyond  control. 

The  defects  of  the  brain  and  nervous  system  from 
parents  of  this  class  are  transmitted,  and  it  is  often 
an  easy  task  to  predict  from  a  history  of  the  parents 
and  their  environment  the  direction  and  form  of 
the  neurotic  degeneration  of  their  children.  While 
these  defects  may  sometimes  skip  a  generation,  in 
the  vast  majority  of  cases  they  appear  again,  and 
often  can  be  traced  back  through  generations  in  the 
diathesis  and  different  predispositions  manifested. 

When  germ  soils  are  present  and  the  conditions 
are  favorable,  morphinism  will  develop  and  grow 
rapidly ;  but  when  the  conditions  are  antagonized  or 
repressed,  it  will  be  diminished,  and  may  die  out 
altogether.  In  almost  every  community  there  are 
numerous  examples  of  these  conditions.  Thus 
where  the  father  is  an  alcoholic  or  moderate  drinker 
and  the  mother  tubercular,  the  children  will  be  bom 
either  unduly  precocious  or  neurotic  and  anemic, 
and  may  become  morphin  or  other  drug  habitues, 
and  often  die  early. 

A  hysteric  mother  and  a  paranoiac  father  may 
have  brilliant  children,  who,  after  a  short,  bright 


Etiology ;  Injuries ;  Shocks  ;  Etc.  69 

career,  fall  into  strange  drug  or  spirit  excesses  and 
die,  A  prominent  instance  of  this  was  that  of  an 
eccentric  father  and  a  hysteric  mother  who  had 
four  children.  One  became  a  brilliant  lawyer,  and 
died  by  morphin.  The  second  was  an  impulsive  re- 
former, who  developed  inebriety  in  middle  life.  The 
third  was  a  banker,  who  proved  a  defaulter.  The 
fourth  disappeared,  leaving  a  large  family,  probably 
dying  in  a  foreign  country. 

Often  children  from  neurotic  ancestry  do  not  de- 
velop these  defects  imtil  middle  and  late  life.  Then 
they  break  up  physically,  morally,  and  mentally,  in 
the  most  extraordinary  way.  Some  of  these  per- 
sons with  defective  ancestors  exhibit  a  high  degree 
of  nervous  development,  approaching  the  type  of 
genius,  starting  far  above  the  average,  and  then 
dropping  dowm  and  disappearing  in  a  very  short 
time,  to  the  astonishment  of  every  one.  Such  per- 
sons not  infrequently  become  morphin-takers  or 
dipsomaniacs,  and  die  from  suicide  or  acute  dis- 
eases. 

Many  families  belong  to  this  unstable  neurotic 
class  whose  dissolution  is  apparent  in  inebriety,  mor- 
phinism, insanity,  and  different  grades  of  mental 
and  moral  pauperism.  They  seem  to  inherit  vacil- 
lating mentality  with  a  special  tendency  to  exhaus- 
tion and  dissolution  from  the  slightest  causes.  It  is 
this  condition  which  finds  most  pleasing  relief  from 


70  Morphinism 

the  narcotism  of  morphin.  Here  it  is  not  used  for 
the  mental  effects  or  exalted  hallucinatory  states, 
but  to  steady  and  control  the  nervous  organization 
and  give  the  rest  and  peace  which  are  constantly 
sought  for  by  the  normal  man. 

From  a  clinical  point  of  view,  it  is  rare  to  find 
cases  of  chorea,  hysteria,  megrim,  or  any  form  of 
inebriety,  including  opium-taking,  in  which  there  is 
not  traceable  some  inherited  predisposition.  Many 
of  the  ancestors  of  persons  suffering  from  these  dis- 
eases may  not  have  possessed  markedly  nervous 
temperaments,  but  by  reason  of  occupation,  sur- 
roundings, and  neglect  of  hygienic  living,  have  de- 
veloped neuroses  which  are  transmitted  to  their 
children.  Thus,  overwork,  underwork,  nutrient  ex- 
cesses, and  neurotic  strains  are  active  causes  which 
entail  upon  the  next  generation  defects  that  find 
relief  in  spirit-  and  drug-taking.  The  children  of 
such  parents  often  find  in  morphin  the  first  pleasur- 
able sensations  and  relief  from  discomfort  and  pain. 
This  drug  seems  to  put  them  in  a  normal  condition 
with  a  positive  sense  of  physical  satisfaction ;  life  is 
full  of  zest;  the  mental  and  physical  vigor  seems 
perfect.  The  sense  of  strength  is  a  delusion,  to 
maintain  which  larger  doses  are  required,  which 
in  itself  is  a  significant  warning. 

Next  to  this  diathesis  or  inherited  predisposing 
cause  there  is  a  vast  realm  of  acquired  causes,  which 


Etiology;  Injuries;  Shocks;  Etc.  71 

may  be  described  as  brain  and  nerve  injuries, 
cell  and  tissue  starvation,  autointoxications,  brain 
strains,  and  drains  of  nervous  force.  Persons  suffer- 
ing from  these  conditions  are  always  seeking  relief, 
and  morphin  often  answers  this  purpose. 

When  a  single  dose  temporarily  restores  the  dis- 
turbed equilibrium  and  brings  ease  and  comfort, 
there  is  unmistakable  evidence  of  derangement  of 
the  brain-centers,  either  inherited  or  acquired.  If 
the  effects  of  opium  were  uniform  in  all  cases, 
there  would  soon  be  an  enormous  army  of  opium- 
takers  ;  but,  fortunately,  only  a  limited  number  find 
relief  from  this  source.  It  would  seem  that  this 
minority  is  rapidly  increasing;  at  all  events,  it  is 
becoming  more  and  more  apparent. 

Not  infrequently  in  many  persons  the  effect  of 
morphin  or  opium  is  very  unpleasant  at  first ;  the 
narcotic  action  is  depressing  and  nauseating,  and  a 
marked  irritation  follows,  which  continues  for  some 
time  after  the  drug  has  been  used.  Such  persons 
rarely  become  habitues,  and  seem  to  possess  some 
repelling  power  which  prevents  them  from  using 
it  again. 

A  few  cases  have  been  noted  in  which  the  poisonous 
effect  of  morphin  was  with  difficulty  overcome.  In 
such  cases  a  very  small  dose  was  used.  Cases  of 
this  character  have  occurred  in  the  police-station 
where  inebriates  were  treated.     To  lessen  delirium 


72  Morphinism 

and  excitement  morphin  has  been  given,  and  after 
a  short  period  of  emesis,  narcotism  and  death  fol- 
lowed. The  dose  having  been  very  small,  death  was 
ascribed  to  some  other  cause.  In  reality  it  was  the 
hypersensitiveness  of  the  system  to  the  effects  of 
morphin  and  morphin-poisoning. 

Persons  who  have  suffered  from  sunstroke  or  heat 
prostration,  after  the  use  of  a  small  dose  of  morphin 
are  more  susceptible  to  an  addiction.  Whether  these 
poison-states  were  due  to  idiosyncrasies  or  conditions 
acquired  from  alcohol,  to  the  effects  of  heat,  or  to 
chronic  states  of  nutrition  and  autointoxication,  it 
is  difficult  to  determine. 

In  a  certain  number  of  cases  an  intense  aversion 
follows  the  use  of  morphin.  A  feeling  of  dread  and 
pressure  over  the  heart,  suggesting  heart  failure, 
creates  intense  alarm  in  the  mind,  which  is  never 
overcome.  Persons  having  once  experienced  this, 
seem  to  possess  an  extraordinary  hypersensitiveness 
to  morphin.  Even  when  it  is  disguised  its  effects 
are  recognized,  and  often  cause  serious  results.  Un- 
doubtedly in  some  instances  this  is  psychic.  In 
others  it  is  physical,  and  dependent  upon  some 
peculiar  condition  of  the  nerve-centers. 

Some  children  show  this  extraordinary  sensitive- 
ness to  opium  and  its  preparations.  They  vomit 
and  suffer  from  chills  and  excessive  perspiration, 
with  prostration,  when  it  is  given.     In  other  cases 


Etiology ;  Injuries  ;  Shocks  ;  Etc.  73 

extreme  irritant  effects  are  not  manifest,  but  pro- 
found narcotism  follows  its  use,  lasting  a  long  time 
and  ending  in  general  derangement  of  the  brain  and 
nervous  system.  The  system  seemingly  is  over- 
whelmed by  this  drug,  and  the  sensory  and  motor 
centers  receive  the  full  effects  of  the  narcotism. 

An  example  of  sensitiveness  is  that  of  an  active 
business  man  who  for  insomnia  of  temporary  duration 
was  given  an  eighth  of  a  grain  of  morphin.  The  nar- 
cotism lasted  one  day,  most  of  the  time  profound,  and 
was  followed  by  great  muscular  and  mental  depres- 
sion. Later,  when  a  small  dose  of  opium  was  given, 
the  effects  were  equally  marked  and  long-continued. 
In  another  case  a  man  suffering  from  colic  was  given 
a  quarter  of  a  grain  of  morphin.  He  slept  two  days, 
most  of  the  time  in  a  condition  of  stupor  from  which 
it  was  difficult  to  arouse  him.  These  cases  are  not 
common,  but  are  likely  to  occtir  unexpectedly  at  any 
time. 

Often  alcoholic  inebriates  show  an  extreme 
sensitiveness  to  the  effects  of  morphin  when  given 
in  small  doses,  and  when  quantities  of  spirits  are 
given  to  break  up  the  drug  impression,  the  danger 
to  the  patient  is  increased.  Such  cases  are  found 
dead  on  the  street  or  at  home,  and  the  causes  are 
difficult  to  ascertain. 

There  is  another  quite  large  class  of  neurotics  who 
find  the  first  effect  of  opium  or  morphin  depressing. 


74.  Morphinism 

and  often  associated  with  emesis.  This  passes  off, 
and  a  pleasing  narcotism  follows.  An  example  of  this 
kind  was  a  morphinist  who  had  to  take  brandy  before 
the  use  of  morphin  to  prevent  the  nausea. 

Other  persons  take  extraordinary  precautions  to 
avoid  the  first  effects  of  morphin,  by  lying  in  bed, 
placing  compresses  over  their  abdomen,  or  using 
irritants  to  the  feet  until  the  narcotic  action  be- 
gins. A  certain  number  of  cases  have,  by  persist- 
ing in  the  use  of  morphin,  overcome  these  early 
irritant  effects  and  secured  a  degree  of  toleration 
which  prevents  the  emesis,  irritation,  and  dis- 
comfort. 

In  other  cases  this  repelling  power  continues 
through  a  whole  lifetime,  and  the  first  effect  of 
each  dose  of  morphin  is  some  obscure  shock, 
manifest  in  paleness,  depression,  and  emesis  if  the 
stomach  is  actively  at  work.  This  lasts  from  a  few 
moments  to  an  hour;  then  the  pleasing  narcotism 
seems  to  restore  the  equilibrium,  and  quietness  and 
sleep  follow. 

In  a  certain  number  of  neurotics  there  is  intense 
mental  repugnance  to  the  demand  for  morphin,  and 
a  conflict  between  the  will  and  the  morbid  impulses 
takes  place  on  every  occasion  of  its  use.  This  re- 
sembles the  alcoholic,  who  often  has  extreme  repug- 
nance to  the  taste  and  effects  of  alcohol,  but  who  is 
impelled  by  a  morbid  impulse  to  overcome  this 


Etiology ;  Injuries  ;  Shocks ;  Etc.  75 

antagonism.  These  cases  contrast  very  strongly 
with  those  in  which  the  first  effect  of  morphin  is 
pleasing  and  tranquilizing,  and  indicate  a  certain 
abnormal  condition  which  is  favorable  to  its  nar- 
cotic action. 

The  history  of  a  certain  number  of  morphinists 
points  to  brain  and  nerve  injuries  as  the  starting- 
point  of  their  addiction.  In  these  cases,  diseases, 
shocks,  and  mental  perturbations  and  exhaustions, 
with  lowering  of  the  vital  forces,  have  damaged  the 
functional  and  organic  activities,  creating  a  strong 
tendency  to  seek  relief  in  narcotism.  Examples  like 
the  following  are  common: 

An  active,  temperate  business  man  suddenly  lost 
all  his  property,  and  as  a  result  suffered  from  some 
obscure  condition  of  brain  inflammation.  He  was 
treated  for  delirium,  prostration,  and  great  mental 
excitement  for  several  weeks ;  then  recovered.  Later, 
he  began  to  use  morphin,  and  finally  became  a 
morphinist.  It  is  difficult  to  tell  how  and  why 
morphin  was  first  used — whether  from  a  doctor's 
prescription  or  by  an  accidental  discovery  of  its 
soothing  effects. 

Another  case  is  that  of  a  man  struck  on  the  head 
and  made  unconscious,  who,  after  recovery,  was  ex- 
cessively nervous  and  insomniac,  and  who  in  some 
unknown  way  became  a  morphinist. 

Many  veterans  of  the  Civil  War  became  morphinists 


76  Morphinism 

to  relieve  the  pain  and  suffering  following  injuries  re- 
ceived in  the  service,  and  the  addiction  is  often  con- 
cealed to  prevent  the  possibility  of  imperiling  their 
application  for  a  pension.  The  theory  obtains  that 
morphin-taking  is  a  wilful  vice  and  the  disabilities 
from  its  use  should  not  be  recognized  by  the  Pension 
Bureau.  In  Prussia  both  alcohol  amd  opium  inebriety 
are  treated  as  diseases  when  occurring  in  the  army 
or  civil  service,  or  following  a  period  of  service,  and 
receive  the  same  consideration  as  if  they  were  physi- 
cal injuries.  The  sufferings  and  hardships  growing 
out  of  the  perils  of  war  often  react  in  illness,  nerve 
and  brain  instability,  and  feebleness,  and  the  use  of 
morphin  is  a  symptom  of  damage  from  this  source 
which  should  be  recognized  as  its  nattiral  entailment 
and  sequel  by  the  Pension  Bureau. 

Many  persons  who  were  in  active  service  in  the 
Civil  War  came  out  in  apparent  health,  not  having 
received  any  injury  or  been  ill.  While  they  suffered 
from  the  usual  strains  and  privations  and  exhaus- 
tion incident  to  the  march  and  battle-field,  for 
years  afterward  there  seemed  to  be  no  evidence  of 
injury  in  their  appearance  and  health.  Then,  from 
some  very  insignificant  causes,  they  suddenly  be- 
came invalids  and  morphinists.  Evidently  there 
was  some  causative  relation  between  the  exhaustion 
and  sufferings  of  army  life  and  the  sudden  develop- 
ment of  morphinism.     Some  profoimd  impairment 


Etiolog}' ;  Injuries  ;  Shocks ;  Etc.  *]*] 

of  the  nerve-centers  existed  which  was  covered  up 
until  middle  life ;  then  appeared  with  the  decline  of 
the  bodily  vigor.  This  is  often  manifest  in  the 
neurotic  and  nutrient  disturbances  which  find  most 
perfect  relief  from  the  narcotism  of  morphin.  The 
following  are  examples: 

An  officer  who  served  for  three  years  in  the  Civil 
War  was  discharged  apparently  in  good  health.  He 
had  been  a  prisoner  for  some  months,  and  also  suf- 
ered  from  the  usual  deprivations  and  excitements  of 
the  severe  campaigns.  He  became  a  teacher,  and 
lived  a  quiet  life  for  fifteen  years;  then  suddenly, 
without  any  special  cause,  was  intensely  nervous 
and  insomniac,  and  used  morphin  for  relief.  From 
this  time  he  continued  its  use  both  secretly  and 
openly,  degenerating  into  an  extremely  chronic 
state,  finally  taking  spirits  and  cocain  and  other 
drugs  on  all  occasions.  Deserted  by  his  friends,  he 
died  in  a  pauper  hospital. 

The  second  example  is  that  of  a  private  who 
served  through  two  years  of  very  active  campaign- 
ing, and  was  discharged  as  healthy  and  well.  He  was 
in  many  battles  and  suffered  from  continuous  excite- 
ment and  exposure,  but  was  never  ill  nor  incapaci- 
tated for  duty.  He  studied  and  became  a  physician, 
and  was  a  strong,  temperate  man.  Finally  he  was 
made  superintendent  of  an  insane  asylum.  Twenty 
years  after  the  discharge  from  the  army  he  suddenly 


78  Morphinism 

began  to  drink  spirits  to  intoxication.  He  gave  no 
reason,  and  there  seemed  to  be  no  explanation  for  its 
use.  Later,  he  gave  up  spirits  for  morphin  and  retired 
to  private  practice,  refusing  all  attempts  at  cure,  and 
finally  died  a  morphin  imbecile. 

These  are  not  unusual  cases.  They  may  be 
ushered  in  by  an  attack  of  rheumatism  or  obscure 
and  painful  neuroses,  which  sooner  or  later  find 
relief  from  narcotic  drugs.  In  some  instances  the 
relation  between  the  strains  of  army  life  and  this 
strange  craving  for  narcotics  is  clear  and  traceable; 
in  others  it  is  obscure.  The  sudden  appearance  of 
exhaustion  and  collapse  of  vigor  and  power  of  re- 
sistance, with  dominance  of  the  impulse  for  narcotics 
and  relief,  point  out  clearly  some  damage  and  im- 
pairment of  the  brain-centers. 

A  still  larger  number  of  cases  are  noted  who  have 
been  injured  by  heat  and  sunstroke,  then  recovered, 
and  later  became  morphinists.  Some  obscure  brain 
and  nerve  injury  has  preceded  the  addiction.  In 
some  instances  morphin  was  used  as  a  remedy  under 
the  care  of  a  physician.  In  others  it  was  taken  up 
surreptitiously,  and  was  the  direct  result  of  physical 
injury  and  its  consequent  weakness.  It  is  probable 
that  in  these  cases  the  narcotism  from  morphin  pro- 
duced the  first  pleasing  relief  from  pain  and  dis- 
comfort which  they  had  ever  experienced. 

Recently  some  cases  have  been  noted  where  the 


Etiology  ;  Injuries  ;  Shocks  ;  Etc.  79 

correction  of  astigmatic  states  and  irregularities  of 
the  eye  have  been  followed  by  recovery  from  the 
morphin  addiction.  In  all  probability  the  irritation 
and  exhaustion  due  to  the  eye-strain  provoked  the 
use  of  morphin,  and  when  this  was  removed  the 
morphin  was  distasteful  and  could  be  abandoned 
readily. 

There  is  another  class  of  causes  traceable  in  a  study 
of  morphinism  which  are  evidently  due  to  cell  and 
tissue  starvation.  It  is  apparent  from  the  history 
that  anemia,  lowered  vitality,  and  inefficient  nourish- 
ment have  preceded  the  use  of  morphin ;  also  in  some 
instances  in  convalescent  states  following  protracted 
fevers  or  overwork  its  use  has  begun.  Thus,  a 
man  convalescing  from  pneumonia  or  typhoid  fever, 
who  is  in  a  state  of  semi-starvation,  and  who  suffers 
from  insomnia  and  extreme  depression,  finds  relief 
and  comfort  from  small  doses  of  morphin.  The 
effect  is  so  pronounced  that  its  use  is  continued. 

Persons  who  are  burdened  with  cares  and  respon- 
sibilities and  are  ill  nourished  find  in  morphin  the 
same  solace  and  freedom  from  all  their  pains  and 
aches. 

Early  autointoxications  are  clearly  causes  which 
produce  disordered  appetites,  headaches,  brain 
fatigue,  fever,  and  states  of  irritability  and  in- 
stability for  which  morphin  is  often  a  relief. 
There  is,  no  doubt,  a  great  variety  of  conditions 


8o  Morphinism 

dating  from  these  self-poisonings  which  produce 
disturbances  in  the  system  that  morphin  most 
effectually  covers  up,  creating  the  semblance  of 
cure,  while  in  reality  it  increases  the  very  condition 
it  is  supposed  to  relieve.  After  a  time  the  demand 
for  morphin  is  additional  evidence  of  the  central 
degeneration. 

This  great  army  of  functionally  disturbed  in- 
valids, whose  pains  and  aches  and  symptoms  are 
legion,  all  furnish  congenial  soils  for  the  growth  of 
the  opium  addiction.  They  are  uniformly  anemic 
and  hyperesthetic,  and  suffer  from  all  degrees  of 
pains  and  discomforts.  The  brain  is  neurasthenic 
and  neuralgic;  fatigue  congestions  and  derange- 
ments are  present,  with  organic  as  well  as  functional 
changes. 

A  prominent  author  *  has  described  this  class  as 
follows:  "They  are  the  physical  and  mental  misers, 
or  persons  suffering  from  all  imaginative  degrees  of 
distress  and  poverty,  neglecting  themselves,  and 
subject  to  complex  delusions.  They  are  paranoiacs 
and  dyspeptics  and  general  neurotics.  There  is  al- 
ways present  cell  and  tissue  starvation.  Poisonous 
waste-products  are  continually  forming  in  the 
system.  There  is  deranged  assimilation  and  elimina- 
tion, and  the  nerve-centers  are  often  overwhelmed 
by  chemical  irritants  and  toxins." 

♦Hughes:  "Alienist  and  Neurologist,"  1900. 


Etiology;  Injuries;  Shocks;  Etc.  8i 

These  persons  range  all  the  way  from  the  most 
intellectual  down  to  the  very  poor  and  i^iprant, 
and  include  a  large  number  of  the  border-land  victims 
who  live  both  mentally  and  physically  on  the 
frontiers  of  sanity  and  insanity.  There  are  nutrient 
impairment,  nerve  defects,  brain  exhaustion,  organic 
and  functional  degenerations.  Opium  or  one  of  its 
alkaloids  comes  as  a  revelation,  covering  up  the 
protests  of  the  defective  cells  and  irritated  nerves. 
The  original  damage  is  concentrated  and  intensified 
along  new  and  tmexpected  lines. 

A  certain  number  of  cases  have  been  traced  to  the 
exhaustion  incident  to  age  and  breaking  up  of  the 
brain  and  nervous  systems,  especially  in  men  and 
women  who  have  been  very  active  or  have  been 
subjected  to  great  changes  in  their  Hves.  The 
change  of  life  in  women  is  often  followed  by  physical, 
psychic,  and  prolonged  functional  disturbances 
which  crave  relief.  Men  who  have  credulous  faith 
in  the  power  of  drugs  to  relieve  and  restore  the 
body,  and  who  believe  in  the  old  adage  that  nature 
has  provided  means  for  the  relief  of  all  pain  and 
suffering,  are  also  predisposed  to  become  morphin- 
ists. Such  persons  readily  become  addicted,  and 
for  a  time  believe  they  have  fotmd  the  panacea 
of  their  dreams. 

A  few  instances  have  been  mentioned  of  general 

paresis  being  preceded  by  morphinism.     In  these 
6 


82  Morphinism 

cases  it  is  difficult  to  determine  which  was  the 
original  disease.  Morphinism  apparently  started  from 
neuralgia  and  insomnia,  and  after  a  few  years'  use  of 
the  drug  well-marked  symptoms  of  paresis  ap- 
peared. The  early  neuralgias  may  have  been  symp- 
toms of  paresis  which  were  concealed  by  the  mor- 
phin,  and  possibly  the  paresis  was  retarded  in  some 
degree  by  the  constant  narcotism.  In  two  cases 
of  this  character  the  use  of  morphin  was  more  im- 
ptdsive,  and  the  person  seemed  dependent  upon  it, 
and  became  maniacal  when  it  was  removed.  There 
are  some  reasons  for  believing  that  these  symptoms 
were  due  to  the  degeneration  from  paresis. 

An  example  illustrating  this  class  of  cases  was  that 
of  a  lawyer,  aged  forty-one.  He  was  an  active,  tem- 
perate man,  having  charge  of  a  large  estate  requiring 
great  care  and  responsibility.  Suddenly  he  suffered 
from  nervousness  and  insomnia,  and  began  to  use 
morphin,  and  was  improved.  During  the  next  five 
years  he  tried  to  give  up  the  drug,  but  became 
delirious  when  the  amount  was  reduced.  He  had 
delusions  of  poverty  and  sudden  death,  but  when 
the  morphin  was  increased  these  passed  away. 
Finally  the  morphin  was  withdrawn  in  an  institu- 
tion, and,  on  recovery,  well-marked  symptoms  of 
paresis  appeared.  He  began  the  use  of  morphin 
again,  and  lived  two  years,  dying  from  pneumonia. 
The  paresis  had  become  prominent,  and,  although 


Etiology ;  Injuries ;  Shocks ;  Etc.  83 

masked  by  the  narcosis  of  morphin,  seemed  to  be 
accelerated.  In  all  probability  the  paresis  began 
with  the  first  symptoms  of  nervousness  and  in- 
somnia, and  may  have  been  retarded  at  first,  but 
afterward  increased,  by  the  effect  of  the  morphin. 

In  a  certain  number  of  cases  morphin  has  been 
given  for  neuralgic  spasms  of  the  stomach.  Later 
it  was  found  that  these  pain  spasms  were  the  gas- 
tric crises  of  ataxias.  Morphin  addiction  followed 
rapidly,  and  the  drug  could  not  be  withdrawn  with- 
out extreme  suffering.  Often  the  ataxias  are  not 
recognized  in  the  early  stages.  In  a  patient  under  the 
author's  care  the  withdrawal  of  morphin  revealed 
the  real  condition,  with  the  paroxysmal  pain  and 
other  symptoms  which  had  been  observed  before. 
The  pains  were  so  intense  that  he  soon  relapsed,  and 
continued  the  use  of  the  morphin  until  death  some 
years  later.  A  number  of  ataxics  are  morphinists 
because  of  these  gastric  pains  at  first,  and  they 
rarely  ever  abandon  the  drug.  Nothing  else  gives 
such  relief.  Death  follows  from  both  the  drug  and 
the  degeneration  of  the  cord. 

One  author  has  mentioned  malaria  as  a  very 
active  cause,  and  has  cited  a  number  of  cases  to 
sustain  his  assertion.  There  can  be  no  doubt  that 
the  sequels  of  malaria  have  merged  into  this  addic- 
tion. In  all  probability  certain  special  favoring 
causes  have  predisposed  to  the  addiction,   which 


$4  Morphinism 

may  have  existed  before  the  malaria  came  on.  The 
neuralgias  following  malaria  and  other  disturbed 
conditions  are  not  always  relieved  by  opium  or  its 
alkaloids,  hence  the  addiction  therefrom  is  not  very 
common.  The  effects  following  the  use  of  morphin  in 
organic  diseases  of  the  stomach,  liver,  or  other  parts 
differ  frequently  from  those  of  a  malarial  origin  in 
which  morphin  is  taken  as  a  remedy.  Very  rarely 
does  any  irritant  effect  follow  the  use  of  morphin  in 
these  organic  cases. 

How  far  the  narcotism  of  morphin  arrests  the 
acute  diseases  is  difficult  to  determine.  In  some 
instances  this  result  is  very  marked;  in  others,  the. 
progress  of  the  disease  is  accelerated.  Some  authors 
have  urged  the  value  of  opium  and  its  alkaloids  in 
different  forms  of  cancer  associated  with  great  pain, 
and  have  asserted  that  the  progress  of  the  disease 
was  diminished  and  life  prolonged  by  the  use  of  the 
drug.  It  is  probable  in  these  cases  that  the  removal 
of  pain  is  the  most  influential  factor.  Where  the 
pain  centers  are  hyperesthetic,  the  use  of  opium  will 
have  some  retarding  effect  on  the  progress  of  the 
disease.  Where  tumors  and  organic  growths  in  the 
body  are  not  painful,  the  retarding  effect  of  morphin 
will  not  be  noticed. 

Recently  morphinism  has  been  traced  to  the  pain 
following  surgical  operations.  In  these  cases  the 
drug  is  given  in  small  doses  after  operations  for  a 


Etiology;  Injuries;  Shocks;  Etc.  85 

considerable  time,  and  is  followed  by  an  addiction. 
If  the  person  has  used  morphin  or  alcohol  before  the 
operation,  there  is  in  many  instances  a  peculiar 
susceptibility,  which  appears  in  the  very  pleasing 
effects  when  it  is  given  afterward.  In  several 
instances  its  early  use  is  concealed  and  unsus- 
pected, but  it  becomes  apparent  after  the  opera- 
tion. A  number  of  cases  of  appendicitis  were  found 
after  the  operation  to  be  morphinists;  severe  com- 
plications have  followed.  In  some  instances  where 
morphin  has  been  used  surreptitiously,  the  surgeon, 
not  knowing  how  to  account  for  the  after-symptoms, 
has  looked  upon  the  case  as  one  of  great  gravity. 

In  a  case  of  amputation  of  the  lower  extremities 
for  railroad  injury  a  peculiar,  exhausting  delirium  ap- 
peared the  second  day,  and  was  not  diagnosed  until 
the  interne  gave  an  injection  of  morphin.  It  was  then 
ascertained  that  the  person  was  a  secret  morphin- 
taker.  All  bad  symptoms  subsided  and  recovery 
followed  after  the  drug  was  again  given  regularly. 

It  may  be  stated  as  a  general  rule  that  both  the 
physical  and  psychic  shocks  which  the  brain  and 
nervous  system  receive  from  a  surgical  operation 
and  from  the  anesthesia  of  chloroform  and  ether 
often  derange  the  nerve  stability,  increasing  the 
susceptibility  to  pain  and  making  the  use  of  mor- 
phin dangerous  if  given  afterward.  Of  course,  much 
depends  upon  the  person.     When  they  are  neuras- 


86  Morphinism 

thenic  or  worn  out  from  disease,  the  susceptibility 
is  greater.  In  operations  in  which  a  large  amount 
of  blood  has  been  lost,  or  where  large  nerve-trunks 
are  cut  across  and  wide  surfaces  are  exposed,  un- 
doubtedly the  susceptibility  to  the  addiction  of 
morphin  and  other  narcotics  is  increased.  In- 
stances are  reported  where,  after  a  severe  surgical 
operation  and  prolonged  etherization,  morphin 
addiction  appeared.  In  all  probability  the  addic- 
tion began  soon  after  the  operation,  and  was  con- 
cealed until  it  became  chronic. 

A  healthy  business  man  of  middle  life  sustained  a 
severe  fracture  of  the  femur.  Some  months  after 
a  surgical  operation  the  fractured  ends  were  removed 
under  the  influence  of  ether.  In  a  year  his  conduct 
and  manner  so  changed  that  mental  impairment  was 
suspected.  Later  it  was  found  to  be  due  to  morphin 
addiction,  which  he  was  powerless  to  resist,  but  which 
he  showed  great  ingenuity  in  efforts  to  conceal.  In 
another  case,  after  an  operation  for  hemorrhoids  the 
person  recovered,  and  soon  after  began  to  use  a 
morphin  suppository  for  some  pain  and  discomfort. 
From  that  time  he  became  a  morphinist. 

In  these  cases  there  was  present  a  hyperesthetic 
sensitiveness  to  pain,  with  little  or  no  resisting  power. 
In  a  certain  number  of  instances  the  effect  of  pro- 
longed anesthesia  gives  a  great  susceptibility  to 
morphin. 


Etiology;  Injuries;  Shocks;  Etc.  87 

Some  cases  are  reported  of  morphinism  dating  from 
etherization  following  tetanoid  spasms.  Quite  a 
number  of  cases  have  followed  the  free  use  of  mor- 
phin  in  prolonged  and  painful  labors,  especially 
where  it  has  been  given  after  the  labor  for  a  time. 

It  has  been  stated  with  great  emphasis  that  all 
operations  which  profoundly  impress  the  nervous 
centers,  lowering  the  normal  vigor  of  the  body,  in- 
crease the  sensitiveness  to  pain  and  diminish  nerve 
coordination  and  power  of  resistance,  leaving  the 
person  very  susceptible  to  morphin. 

Within  a  few  years  many  authorities  have  pointed 
out  the  danger  of  morphinism  in  women  who  come 
under  treatment  for  gynecologic  disorders.  The 
impulse  to  secure  relief  from  pain  and  to  induce 
sleep  is  so  imperative  that  morphin  is  taken  without 
regard  to  its  perils.  The  patient  is  both  physio- 
logically and  psychologically  impressed  with  the 
intense  satisfaction  of  rapid  relief,  and  ever  after 
this  impression  becomes  dominant  in  pain  and 
suffering.  All  control  of  the  will,  feelings,  and 
emotions  is  overcome  by  it.  The  desire  to  escape 
pain  and  suffering  becomes  in  many  cases  a  mania. 

Capriciousness  of  mind,  irritability,  selfishness, 
restlessness,  and  excitability  are  the  natural  char- 
acteristics of  many  women,  who  quickly  become 
morphinists,  especially  if  under  treatment  for  dis- 
orders   of    the    generative    organs.     Such    persons 


88  Morphinism 

suffer  from  uterine  troubles  and  ovarian  troubles, 
and  disturbances  of  all  types  and  grades,  with  in- 
tense depression  and  exhaustion  of  the  nervous 
system. 

Hysteria,  neurasthenia,  neuralgia,  cephalalgia, 
ovarian  crises,  dysmenorrhea,  spinal  neuropathies, 
neuromimesis,  are  the  correlated  conditions,  often 
associated  with  sexual  disturbances,  forming  fertile 
soil  for  the  production  and  growth  of  morphinism. 
Many  instances  are  noted  in  which  the  use  of  mor- 
phin  first  prescribed  by  a  physician  has  been  con- 
tinued secretly.  The  results  were  so  pleasurable 
that  the  tendency  often  arises  to  recommend  its 
use  to  others,  and  in  this  way  the  addiction  has 
become  contagious,  spreading  in  some  instances 
throughout  the  community.  Women  are  more  sus- 
ceptible than  men  if  there  is  a  similar  neurosis. 

Recently  a  great  reaction  has  been  noticed  in  the 
use  of  opium  and  its  alkaloids  in  surgical  cases. 
Many  leading  surgeons  condemn  the  use  of  morphin 
in  certain  capital  operations.  It  is  authoritatively  as- 
serted that  the  statement  so  often  made  to  students, 
that  their  mission  is  to  relieve  pain  and  suffering, 
has  been  fraught  with  the  most  disastrous  conse- 
quences. Dr.  Joseph  Price*  writes  as  follows  on 
this  subject : 

"I  am  satisfied  that  the  use  of  opium  in  some 

*  "  Journal  of  the  American  Medical  Association,"  July,  1900. 


Etiology  ;  Injuries  ;  Shocks  ;  Etc.  89 

form,  either  by  injection,  suppository,  or  solution, 
should  be  held  largely  responsible  for  much  of  the 
high  mortality  in  abdominal  surgery,  I  have 
watched  the  work  of  others  and  compared  the 
mortality  of  the  operators  who  use  it  with  those  who 
reject  it,  and  I  find  a  large  difference  in  the  mortality 
lists.  Those  who  do  not  use  it  have  the  lowest 
mortality.  The  use  and  abuse  of  it  before  painful 
troubles  are  removed  obscures  symptoms,  impairs 
nutrition,  and  greatly  complicates  the  management 
of  the  patient.  Without  opiates,  you  have  a  certain 
cooperation  of  the  patient,  and  the  pain  signals  are 
limited  and  appreciable  for  a  short  time  following 
operations.  Many  imcomfortable  and  threatening 
conditions  are  wholly  absent  when  opium  is  not  given. 
In  addition  to  this,  there  is  the  strong  probability  of 
contracting  an  addiction,  and  the  continuous  use  of 
opium  after." 

The  doctor  illustrates  his  views  in  the  record  of 
four  cases  where  general  peritonitis  existed.  The 
operation  and  after-treatment  were  without  opium, 
and  the  results  were  most  satisfactory.  There  is 
evidently  just  ground  for  fears  of  the  danger  of 
opium  in  these  cases. 

Dr.  Macnaughton  Jones*  has  called  attention  to 
the  special  danger  coming  from  the  use  of  morphin 
in  gynecologic  practice.     He  has  pointed  out  cer- 

*  "  Journal  of  Inebriety,"  July,  1895. 


90  Morphinism 

tain  classes  of  neiirotic  women  noted  for  capricious- 
ness,  irritability,  and  restless  excitability,  to  whom 
the  effects  of  morphin  are  a  panacea  which  they  do 
not  give  up  when  once  they  have  experienced  its 
pleasure.  Such  persons  find  relief  from  morphin, 
no  matter  how  administered,  and  soon  are  unable 
to  do  without  it.  Dr.  Jones  believes  that  most  of 
the  morphinomaniacs  among  women  will  be  found 
to  have  had,  prior  to  the  addiction,  hysteria,  neu- 
rasthenia, neuralgia,  ovarian  crises,  dysmenorrhea, 
spinal  neurosis,  and  neuromimesis,  or  some  of  the 
great  variety  of  correlated  conditions.  He  thinks 
that  to  give  it  in  cases  of  pregnancy  to  lessen  some 
peculiar  pain  or  condition  is  to  produce  a  tendency  to 
abortion  and  lower  the  vitality  of  the  embryo.  When 
given  for  operations  in  cases  of  this  kind,  it  not  only 
masks  the  dangerous  symptoms,  but  increases  them 
and  adds  new  perils  to  the  present  condition. 

Dr.  Jones  is  certain  that  women  are  more  suscep- 
tible to  morphin  than  men,  and  its  sedative  effects 
are  more  pleasing  and  of  longer  duration.  This  has 
been  also  the  experience  in  this  country.  Morphin 
addiction  among  women,  while  growing  more  and 
more  common,  does  not  differ  from  that  noticed  in 
men.  The  treatment  may  be  somewhat  more  com- 
plicated, but  it  is  substantially  the  same.  There  is 
clearly  a  special  danger  in  using  morphin  in  diseases 
and  operations  on  women,  not  only  in  the  addiction 


Etiology;  Injuries;  Shocks;  Etc.  91 

which  may  follow,  but  the  complicated  neuroses 
which  are  likely  to  follow  its  use. 

Dr.  Jones  is  clear  and  emphatic  in  his  denuncia- 
tions of  its  employment  after  abdominal  operations, 
and  believes  that  its  value  is  limited  to  a  few  cases 
of  organic  diseases  associated  with  extreme  pain. 
Even  here  its  use  may  be  injudicious.  There  is 
probably  more  clandestine  use  of  morphin  among 
women,  but  concealment  cannot  be  continued  long; 
its  effects  are  apparent  in  other  symptoms.  Dr. 
Jones  thus  sums  up  his  conclusions : 

"  First,  the  risk  attending  the  use  of  morphin  in 
the  treatment  of  the  affections  of  the  pelvic  organs 
is  not  sufficiently  recognized. 

"  Second,  the  influence  of  temperament  should  be 
carefully  considered  in  its  administration,  hysterical 
and  so-called  neurotic  temperaments  being  more 
susceptible  and  more  likely  to  be  followed  by 
dangerous  effects  of  the  drug. 

"  Third,  in  such  cases  morphin  should  only  be  used 
as  a  dernier  ressort,  and  rarely,  if  ever,  for  the  relief 
of  what  may  be  said  to  be  subjective  pain.  This  is 
true  both  of  cases  of  ovarian  neuralgia  and  reflex 
ovarian  pains,  and  also  of  spinal  pains  and  reflex 
disorders  of  the  generative  organs  or  an  insomnia 
rising  from  the  same  cause. 

"  Fourth,  its  use  is  particularly  dangerous  in  the 
climacteric. 


92  Morphinism 

"  Fifth,  the  risk  of  morphin  intoxication  and  mor- 
phinism should  be  avoided  as  far  as  possible;  first, 
by  the  medical  man  himself  under  exceptional  cir- 
cumstances and  conditions;  second,  by  limiting  the 
quantity  of  solution  required  for  the  time  and  place, 
preventing  its  being  repeated  except  under  special 
orders ;  third,  by  not  giving  into  the  patient's  hands 
the  needle  or  a  prescription  for  morphin ;  fourth,  all 
friends  and  patients  themselves  should  be  warned 
against  the  use  of  this  drug  except  under  the  advice 
of  physicians.  As  a  rule,  patients  do  better  without 
morphin  after  abdominal  operations." 

Dr.  Jones  has  shown  that  there  is  always  a  cer- 
tain tendency  in  morphin  to  accumulate  in  the 
liver.  The  experiments  of  Rogers  indicate  an  inter- 
action between  the  hepatic  glycogen  and  the  mor- 
phin, the  glycogen  having  the  property  of  arresting 
the  alkaloid,  which  Regnier  believes  to  explain  the 
occurrence  of  glycosuria  in  the  more  advanced 
morphinomaniacs.  It  is  evident  that  if  a  large 
quantity  of  morphin  is  taken  daily,  it  is  not  used 
in  the  system,  from  the  fact  that  it  is  found  in  the 
urine  and  can  be  cut  off  without  the  production  of 
any  particular  distress. 

Among  the  most  interesting  of  the  obscure  causes 
of  morphinism  are  the  psychic  injuries.  These  are 
very  largely  mental  shocks  from  sudden,  violent 
emotional  perturbations  and  mental  strains.     The 


Etiology ;  Injuries ;  Shocks ;  Etc.  93 

most  common  causes  are  sudden  loss  of  property  or 
position,  or  death  of  friends  or  relatives,  entailing 
on  the  mind  extreme  depression  and  profound 
melancholia.  In  other  cases  elation,  joy,  and 
sudden  prosperity  seemingly  have  a  like  effect  in 
breaking  up  the  stability  of  the  nerve-centers. 
Sudden  fright,  dread,  and  fear  of  death  are  not  un- 
common causes.  The  wreck  of  a  railroad  train  or 
the  perils  of  a  threatened  shipwreck,  where  the  mind 
is  wrought  up  to  a  great  intensity,  or  profound 
disappointment  at  some  unlooked-for  event,  are  all 
common  causes  that  have  a  very  pronounced  im- 
pression upon  the  organism. 

Injuries  of  this  character  are  sooner  or  later  fol- 
lowed by  changes  of  the  brain  and  nerve-cell,  mani- 
fest in  slight  and  obscure  disturbances  at  first,  but 
which  after  a  time  grow  to  great  proportions  and 
become  marked  deviations  from  previous  health 
lines.  The  same  low  resisting  power  to  pain  in  the 
sensory  centers,  dread  of  suffering,  low  vitality,  and 
desire  for  relief  are  marked  in  most  cases.  The 
remark  is  often  made  among  thoughtful  men  that 
from  such  and  such  a  time,  referring  to  some  psychic 
shock  or  emotional  disturbance,  they  never  have 
been  the  same;  that  they  are  conscious  of  being 
weakened  and  of  having  less  nerve  and  force  from 
that  time.  This  is  only  a  consciousness  of  injury 
which  all  persons  do  not  experience.     When  such  a 


94  Morphinism 

man  is  given  morphin  and  the  effects  are  pleasing,  it 
is  a  revelation  to  him  of  the  possibility  of  escape, 
and  very  often  is  the  beginning  of  an  addiction  which 
he  is  unable  to  resist. 

An  example  of  this  class  was  that  of  a  strong, 
vigorous  man  who  had  an  encounter  with  a  burglar 
in  his  house.  He  was  shot  at  and  expected  to  be 
killed,  but  escaped.  From  this  time  he  was  greatly 
agitated  from  sounds  and  noises  at  night,  was  in- 
somniac, and  his  mind  was  filled  with  dread  of 
similar  encounters.  The  family  physician  gave 
morphin,  and  from  this  time  he  became  a  mor- 
phinist. 

Another  man,  equally  healthy  and  well,  became 
profoundly  excited  over  the  burning  of  his  mill. 
Although  the  loss  was  insignificant,  it  made  a  pro- 
found impression  on  his  nervous  system.  He  could 
not  explain  it,  but  was  nervous  and  excited,  dreading 
fire  and  accident.  After  a  time  he  became  an  in- 
valid and  drug-taker,  and  soon  found  a  morphin 
prescription  most  efficacious,  and  became  a  victim. 

In  another  case  a  man  in  previous  good  health 
suffered  from  profound  depression  and  disappoint- 
ment at  the  breaking  of  a  marriage  engagement. 
He  had  an  attack  of  acute  rheumatism,  which 
quickly  ended  in  morphinism. 

Many  cases  are  noted  where  these  psychic  sufferers 
find  relief  in  the  use  of  spirits.     When  these  are  taken 


Etiology ;  Injuries  ;  Shocks ;  Etc.  95 

in  excess,  morphin  is  given  to  lessen  the  violence  of 
the  symptoms.  The  spirits  are  then  abandoned  and 
morphin  taken  up.  The  pathologic  condition  is 
no  doubt  a  profound  exhaustion  of  the  cells  and 
their  function,  with  defective  nutrition  and  dimin- 
ished power  of  repair.  Following  this,  pain,  dis- 
comfort, and  unrest  appear,  which  become  more 
and  more  unbearable.  Then  come  drugs  and  nar- 
cotics, which  cover  up  the  pain  and  bring  a  sense 
of  relief  that  is  grateful. 

The  same  condition  probably  follows  the  continued 
use  of  alcohol  in  any  form.  The  nerve  and  sen- 
sory centers  become  deranged,  not  only  by  defec- 
tive nutrition,  but  by  the  presence  of  poison  elements 
which  enfeeble  the  power  of  repair  and  capacity  for 
endurance.  These  symptoms  may  be  temporarily 
concealed  by  the  use  of  spirits,  but  will  gradually 
increase  until  permanent  changes  follow;  then  mor- 
phin is  used,  which  still  further  obscures  and  destroys 
the  danger-signals  of  pain  and  distress.  The  removal 
of  alcohol  gives  some  idea  of  the  damage  done  after 
a  period  of  morphin-taking  followed  by  abstinence ; 
the  aggravated  symptoms  point  unmistakably  to 
a  serious  derangement.  Morphinism  follows  most 
naturally  from  alcoholism,  and  if  a  period  of  alco- 
holic addiction  is  ascertained  in  the  history,  the 
gravity  of  the  case  can  hardly  be  overestimated. 


CHAPTER  IV 

SYMPTOMATOLOGY ;     PECULIARITIES ;     PROG- 
NOSIS  AND    TERMINATION 

First  Symptoms.  Psychologic  Action.  Stimulation  and  Irrita- 
tion. Unconsciousness  of  Its  Effects.  Efforts  to  Conceal  Its  Use. 
Delusions  and  Illusions.  Long-continued  Concealed  Use.  Ap- 
pearance of  the  Eyes.  Emotional  Disturbances.  Stolidity  and 
Nervousness.  Appetite  and  Nutrition.  Bowels.  Mental  Symp- 
toms. Changes  of  Character,  Habits,  and  Mental  Activity.  Heart 
Changes.  Mental  Instability  and  Feebleness.  Delusions  of 
Infidelity  Characteristic.  Never  a  Leader,  but  Always  a  Critic. 
Progress  Uniform  in  Many  Cases.  Unexpected  Death  Common. 
The  Higher  Brain  Suffers  Most.  Changes  of  Symptoms.  Asso- 
ciated Drugs.  Insanity  Symptoms.  Disability  to  Use  Other 
Drugs  to  Conceal  Their  Real  Condition.  Morbid  Fears  and 
Manias. 

The  usual  effect  of  morphin  taken  for  the  purpose 
of  relieving  pain  is  first  that  of  dulness  of  the  senses, 
and  then  obliteration  of  pain,  followed  by  serenity, 
comfort,  and  rest.  Later  a  tendency  to  sleep,  and, 
after  a  short  period  of  unconsciousness,  a  quiet 
wakeful  season  follows.  Later  the  head  begins  to 
ache,  and  nausea  and  depression  come  on.  After  a 
few  doses  the  nausea  and  irritation  disappear,  and 
only  general  heaviness  and  slight  headache  follow. 

When  the  pain  is  psychic,  the  relief  from  morphin 
is  often  so  intense  as  to  produce  a  physiologic  im- 

96 


Symptoms ;  Prognosis  ;  Termination        97 

pression  on  the  nervous  system ;  and  used  the  first 
time,  it  is  a  revelation  and  new  conception  to  the 
mind.  When  the  suffering  is  physical,  the  quietness 
and  rest  which  follow  make  an  equally  strong  im- 
pression, opening  up  a  new  world  of  peace  and 
comfort. 

This  psychologic  impression  is  more  or  less  per- 
manent, and  seems  to  point  out  an  ideal  toward 
which  the  brain  and  nervous  system  turn  with  long- 
ing. When  the  pain  and  discomfort  are  reliev-ed, 
often  irritation  and  vomiting  follow ;  then  this  first 
impression  is  greatly  lessened. 

The  poisonous  action  of  opium  and  its  alkaloids 
for  some  reason  is  more  prominent  in  the  irritation 
than  it  is  in  the  narcotism  which  follows.  The 
irritation  is  the  practical  stimulant  effect  or  apparent 
increase  of  vigor,  both  physical  and  mental,  ending 
in  narcotism. 

Clinically  there  are  two  stages :  one  of  stimulation 

and  irritation,  the  other  of  narcotism  and  stupor. 

* 

The  first  stage  comes  from  small  doses,  and  is  very 
prominent  in  some  persons;  the  second  requires 
larger  doses  or  is  the  result  of  the  cumulative  action 
of  small  doses.  In  each  case  there  is  either  sus- 
ceptibility or  intolerance  to  its  effects.  These  are 
peculiarities  which  often  appear  yery  early  in  the 
history  of  the  case. 

When  the  effects  of  morphin  are  sharp,  distinct, 
7 


98  Morphinism 

and  pleasing,  there  is  susceptibiHty  to  it ;  but  when 
irritation,  excitement,  depression,  and  stupor  follow, 
with  much  headache,  there  is  intolerance.  The 
repelling  stage  or  stage  of  intolerance  not  infre- 
quently passes  away,  and  then  morphin  becomes 
attractive  and  pleasing  in  its  effects.  The  first  stage 
may  be  marked  by  instant  relief  of  pain  and  suffer- 
ing, then  later  be  followed  by  headache,  depression, 
and  poison  symptoms. 

One  who  in  states  of  exhaustion  uses  morphin  as  a 
stimulant,  finds  after  a  few  doses  loss  of  appetite, 
headache,  and  general  dulness.  The  exhilaration 
which  is  sought  reacts  into  depression.  If  morphin 
is  taken  as  an  experiment  by  some  one  who  has 
read  of  its  delirious  effects,  many  of  the  symptoms 
may  be  anticipated  and  are  purely  subjective. 
These  will  grow  less  and  less  from  the  repetition  of 
the  drug,  and  finally  the  first  impression  will  be 
obliterated. 

Innumerable  persons  after  reading  De  Quincey 

have  sought  to  obtain  the  same  results  from  the  use 

\ 

\      of  opium,  but  failed.     There  was  in  De  Quincey's 

1      case  an  exaltation  of  the  imagination  approaching 

i      a  state  of  dehrium,  which  could  seldom  be  repeated 

1      in  other  persons  under  similar  conditions. 

Morphin  dreams  and  illusions  are  so  complex  and 

variable  that  they  cannot  be  described  with  any 

accuracy.     The  early  stage  of  exhilaration  may  be 


Symptoms  ;  Prognosis ;  Termination        99 

evanescent  or  prolonged,  according  to  some  unknown 
condition;  but  when  morphin  has  become  a  neces- 
sity, then  different  symptoms  follow. 

Some  writers  have  divided  the  mental  symptoms 
of  morphinism  into  three  stages :  The  first  is  that  of 
unconsciousness  of  danger  and  extreme  confidence 
in  its  value  for  all  pains  and  aches  and  discomforts. 
There  is  little  caution  in  this  first  stage,  except  to 
use  it  with  other  drugs.  The  increasing  stupor  and 
somnolence  create  a  desire  to  overcome  these  effects. 

This  is  followed  by  the  second  stage,  in  which 
extreme  caution  is  used  to  cover  up  the  use  of  the 
drug  and  to  explain  unusual  symptoms  by  other 
causes.  This  secrecy  grows  until  it  becomes  a 
dominant  idea,  the  patient  taxing  his  ingenuity  and 
skill  to  deceive  and  change  the  appearance  of  every- 
thing. The  erratic  conduct,  foolish  conversation,  and 
puzzling  delusional  states  are  explained  by  most  in- 
genious theories,  urged  by  cultured  persons,  and  the 
real  causes  are  denied. 

X/ater  a  third  condition  of  pronounc^  delusional 
egotism  follows,  in  which  the  use  of  morphin  is 
acknowledged,  with  boasts  of  immunity  from  danger 
and  with  plausible  explanations  of  its  value.  The 
patient  defends  this  condition  and  minimizes  the 
actual  amount  used,  making  assertions  of  being  more 
than  ever  competent  to  determine  the  possibilities 
of  danger.     When  morphin  has  been  taken  by  the 


loo  Morphinism 

needle  at  first,  these  delusional  impressions  of  the 
absence  of  danger  or  possible  injury  increase  with 
great  rapidity. 

At  first  it  is  used  irregularly  and  at  long  intervals, 
seemingly  dependent  on  some  physical  states  of 
stress,  strain,  or  functional  disturbance;  then  it  is 
taken  more  frequently;  and,  finally,  conditions  of 
nervous  anemia  and  prostration  call  for  it  regularly. 
A  sense  of  danger  may  appear,  but  with  this  come 
delusions  of  ability  to  abstain  any  moment  without 
suffering  or  pain. 

Later  the  danger  sense  develops,  and  the  general 
weakness  and  mental  disturbance  at  times  increase 
the  alarm  and  desire  to  give  up  the  drug.  After  a 
great  effort,  with  some  suffering,  this  is  accom- 
plished in  part  by  the  substitution  of  spirits  or  other 
drugs.  Later  the  effects  of  these  are  followed  by 
more  debility  and  exhaustion,  and  morphin  is  re- 
sumed. 

This  alternation  from  one  drug  to  another  may  go 
on  for  some  time.  Finally  some  form  of  morphin  or 
opium  is  permanently  adopted.  Often  this  may  be 
associated  with  spirits  or  beer.  In  some  instances 
morphin  will  be  abandoned  voluntarily  and  without 
help ;  after  a  time  it  is  taken  up  again,  either  openly 
or  secretly,  and  often  without  any  explainable 
cause. 

It  has  been  a  matter  of  surprise  to  all  students  of 


Symptoms;  Prognosis;  Termination      loi 

these  cases  to  find  persons  who  for  years  have  been 
using  small  doses  of  morphin  secretly  without  dis- 
playing any  of  the  common  symptoms.  Such  per- 
sons are  usually  in  the  higher  walks  of  life,  in  pro- 
fessions or  in  business;  many  are  women  of  the 
^wealthier  classes  who  have  nothing  to  do.  Most  of 
these  are  unsuspected,  although  to  their  intimate 
friends,  increasing  eccentricities  of  thought  and  con- 
duct and  diminished  brain  power,  also  secrecy  in 
conduct  of  life,  are  symptoms  of  some  change. 

A  man  at  the  head  of  a  large  corporation,  whose 
character  and  conduct  had  been  above  all  suspicion, 
died  suddenly  from  what  was  supposed  to  be  heart 
failure.  An  examination  showed  his  body  covered 
with  scars  from  morphin  addiction  by  the  use  of 
the  needle.  His  will  betrayed  his  mental  condition 
by  the  eccentricities  of  its  provisions. 

Another  example  was  that  of  gr  iprominent  clergy- 
man, who,  after  his  fiftieth  year  of  age,  became  an 
invalid,  and  was  treated  by  many  physicians  with- 
out success.  After  traveling  for  some  time,  he  died 
suddenly  in  a  hotel.  On  his  body  were  found 
needle  marks  of  morphin  addiction  which  had  ex- 
isted for  a  long  time. 

A  business  man  who  had  been  considered  as  having 
incipient  dementia  was  taken  to  an  asylum,  and  his 
secret  morphinism  discovered.  He  was  treated  and 
recovered.     Four  years  later  he  began  to  decline  in 


I02  Morphinism 

the  same  way.  Repeated  efforts  failed  to  detect  his 
use  of  morphin.  He  continued  five  years  in  active 
business,  growing  more  feeble,  all  the  time  denying 
all  use  of  morphin ;  then  he  died.  It  was  found  that 
he  had  used  both  morphin  and  opium  during  all 
this  time. 

A  case  which  attracted  much  attention  was  that 
of  a  widow,  who  at  forty  suffered  from  shock  by 
railroad  accident,  and  was  given  morphin  by  her 
physician  for  the  insomnia  and  pain.  She  recov- 
ered and  was  considered  well,  and  was  active  in 
managing  her  affairs  up  to  death,  at  sixty-two 
years  of  age.  Her  will  was  contested  and  it  was 
shown  that  she  was  a  secret  morphinist,  having  used 
it  from  the  time  that  she  was  injured,  twenty-two 
years  before.  This  was  unknown  to  her  friends  and 
family,  and  except  some  slight  changes  in  her  judg- 
ment and  manner,  which  were  thought  to  be  due  to 
age,  nothing  was  noticed. 

These  and  many  other  cases  of  like  character 
indicate  the  possibility  of  the  moderate  use  of  mor- 
phin for  a  long  time  without  any  manifested  symp- 
toms. 

The  physical  effects  of  morphinism  vary  widely 
with  the  persons  and  their  occupations.  Probably 
the  most  prominent  are  anemia,  irregularity  of 
thought  and  purpose,  with  spasmodic  muscular  ef- 
forts,  rapid  exhaustion,   and  want  of   endurance. 


Symptoms  ;  Prognosis  ;  Termination      103 

Some  authors  have  laid  great  stress  upon  the  changes 
observed  in  the  eye.  Beyond  that  of  a  contracted 
pupil,  there  is  wide  divergence  of  symptoms  here. 
In  the  later  stages  of  morphinism  the  impaired 
vision  gives  a  certain  fixity  to  the  gaze  and  a  pro- 
longed staring  expression  that  is  abnormal.  Mor- 
phinists who  are  making  great  efforts  to  conceal 
their  addiction  frequently  show  a  furtive  look  in  the 
eye,  resembling  that  of  one  guilty  of  some  crime. 

This  prolonged  gaze  and  the  furtive  movements 
of  the  eyes  are  very  significant.  While  they  may 
not  be  pathognomonic  of  the  secret  use  of  morphin, 
they  indicate  some  condition  of  the  brain  that  is 
abnormal.  These  two  conditions  of  the  eye,  pro- 
longed staring  and  furtive  oscillations,  are  very  com- 
mon in  morphin  cases. 

Some  authors  assert  that  a  watery  eye,  meaning 
an  eye  suffused  with  tears  and  unsteady  and  change- 
able, is  significant  of  drug-taking.  The  contracted 
pupil  is  an  almost  constant  sign,  although  many  mor- 
phinists use  atropin  with  the  morphin  to  dilate 
the  pupil.  The  general  marasmic  appearance  of  the 
face  is  also  another  very  significant  sign.  The  thin 
nostrils,  bloodless  lips,  pale  ears,  and  clear  pearly 
sldn  are  all  associate  symptoms. 

It  is  said  that  a  morphinist  lacks  emotional  ex- 
pression. He  is  unable  to  smile  or  show  interest  in 
a  subject  by  the""play  of  facial  muscles.     This  is 


I04  Morphinism 

probably  true  in  advanced  cases  in  which  there  is 
a  diminished  nerve  activity  almost  amounting  to  pa- 
ralysis. It  may  also  be  true  soon  after  morphin  has 
been  taken,  and  while  the  system  is  under  its  effects ; 
but  when  the  morphin  passes  off,  this  presently  dis- 
appears, and  the  play  of  the  facial  muscles  is  often 
exaggerated. 

A  gentleman  who  attended  the  funeral  of  his 
mother  made  the  most  hysterical  displays  of  grief. 
His  whole  frame  was  agitated  with  emotional  ex- 
citement. Soon  afterward  he  retired  to  his  room, 
fortified  himself  with  the  needle,  and  from  thence- 
forth showed  the  most  stolid  indifference.  He  was 
a  morphinist,  and  had  reduced  the  amount  of  mor- 
phin to  a  low  level,  which  accounted  for  his  extreme 
emotionalism.  After  he  had  taken  the  usual  dose, 
stolidity  and  indifference  followed. 

Two  physical  conditions  have  been  quite  often 
noticed  in  morphinists :  One  of  great  dignity,  slow  re- 
served movement,  all  absence  of  haste,  with  perfect 
command  of  the  muscles,  both  of  the  face  and  body, 
and  a  quiet,  dreamy,  far-away  indifference  to  both 
duty  and  environment.  All  work  is  performed  in  a 
quiet,  dignified  way  without  haste  or  hesitation.  The 
other  condition  is  one  of  unreasonable  nervousness, 
muscular  excitement,  trembling,  with  want  of  co- 
ordination and  general  unsteadiness.  Duties  are 
performed  in  an  impulsive,  abrupt  way,  and  the 


Symptoms  ;  Prognosis  ;  Termination      105 

surroundings  seem  to  have  a  marked  influence  over 
the  minor  actions  of  life. 

These  two  physical  conditions  are  no  doubt  owing 
to  differences  of  temperament,  and  to  the  degree 
of  narcotism  or  amount  of  morphin  which  the 
patient  is  taking  at  the  time,  and  vary  at  times, 
now  distinct,  and  sometimes  merging  into  each 
other.  Some  writers  assert  that  a  morphinist  of 
long  standing  can  be  readily  detected  by  watching 
his  gait  and  manner  of  walking.  It  is  asserted  that 
the  various  degrees  of  paralysis  and  irritation  follow- 
ing large  doses  of  morphin  are  apparent  in  all  the 
movements  of  body  and  head,  and  can  be  noted 
with  any  general  examination.  This  undoubtedly 
applies  to  certain  persons  who  are  unaccustomed  to 
large  doses. 

In  the  early  stages,  with  the  exception  of  the  face 
and  eyes,  there  is  but  little  to  indicate  the  real  con- 
dition physically.  The  appetite  may  be  deranged 
and  digestion  disturbed  and  fitful.  Alternate  con- 
stipation and  diarrhea  are  common.  The  sleep  will 
be  deranged,  sometimes  prolonged  beyond  the  usual 
limits,  then  fitful  and  broken,  the  patient  being 
wakeful  at  night  and  sleeping  through  the  day. 

The  muscles  are  weakened  and  are  unable  to  act 
quickly.  In  an  emergency  they  respond  slowly  to 
the  action  of  the  will.  A  fine  tremor  is  often 
present.     Greneral   sensation   is   affected.     Pruritus 


io6  Morphinism 

and  neuralgias  of  various  sections  of  the  body  are 
prominent  symptoms.  Obstinate  constipation  and 
dysuria  are  not  uncommon.  Vision,  smell,  taste, 
and  hearing  are  greatly  enfeebled.  The  pupils 
are  generally  contracted,  or  greatly  dilated  at 
times.  Anorexia  with  dry  tongue  and  thirst  are 
present.  Hydrochloric  acid  in  the  gastric  juice  is 
absent,  and  there  is  diminished  intestinal  secretion 
and  bile,  followed  by  complex  symptoms  in  the 
gastro-intestinal  tract.  Nutrition  fails,  with  loss  of 
flesh,  and  there  is  edema  about  the  ankles.  The 
skin  becomes  rough,  and  the  sweat  glands  increase 
their  activity,  while  that  of  the  sebaceous  glands  is 
diminished.  This  is  frequently  followed  by  various 
eruptions  and  abscesses.  In  many  cases  the  urine 
is  unaltered,  although  it  frequently  contains  mor- 
phin.  The  sexual  desire  is  sometimes  stimulated 
by  the  first  effects  of  morphin,  then  is  diminished, 
and  finally  destroyed  altogether.  In  women  amen- 
orrhea is  common.  Grave  complications  appear, 
both  mental  and  physical.  Other  drugs  are  substi- 
tuted, which  increase  the  cachexia,  and  final  col- 
lapse. Acute  insanity  is  rarely  seen,  although  melan- 
cholia and  suicide  are  not  uncommon.  Usually 
dementia  of  a  stuporous  form,  associated  with 
muttering  delirium,  terminates  the  case.  Children 
bom  of  mothers  under  the  influence  of  morphin 
have  very  low  vitality,  and  often  die  early. 


Symptoms;  Prognosis;  Termination      107 

The  mental  symptoms  of  morphinism  are  much 
more  pronounced  and  clearly  defined.  Dr.  Lentz  * 
has  tabulated  what  he  considers  to  be  the  most 
prominent  changes  in  morphinism: 

"  First,  the  diminished  power  of  recollection.  In- 
creasing amnesia  or  disability  to  recall  past  mental 
images  and  ideas. 

"  Second,  diminished  power  of  attention  and 
volition. 

"  Third,  diminished  power  of  initiativeness  and 
energy  of  conduct. 

"  Fourth,  diminished  muscular  power,  frequently 
marked  by  trembling. 

"  Fifth,  blunting  of  the  higher  moral  and  ethical 
senses. 

"  Sixth,  insomnia,  loss  of  desire  for  sleep,  and 
nutritive  disturbances  of  the  whole  cortical  sphere. 

"  Seventh,  disturbances  in  the  balance  of  represen- 
tation between  the  external  world  and  the  ego,  with 
false  impressions,  hallucinations,  delusions,  and  sus- 
picions of  wrong." 

These  divisions  undoubtedly  describe  the  condi- 
tions which  occur  more  or  less  prominently  in  every 
case. 

The  first  effect  of  morphin  is  noticed  in  the  de- 
rangement of  the  senses.  The  eye  shows  the  first 
change.     Then  the  hearing  is  duller.     At  first  it  is 

*  "  La  Temperance,"  1894. 


io8  Morphinism 

somewhat  exaggerated,  but  soon  diminishes.  If 
the  person  is  a  musician,  this  is  very  marked  in  his 
decreased  sense  of  sound.  He  will  play  out  of  time 
because  he  cannot  hear  and  think  so  clearly  and 
quickly.  His  sight  of  the  notes  will  be  more  ob- 
scured and  slow.  If  he  is  a  pianist,  his  sense  of  touch 
will  be  less  delicate,  more  irregular,  and  impulsive. 
If  he  is  a  singer,  both  his  sense  of  the  relation  of 
sound  and  tune  will  be  dulled  and  his  capacity  to 
articulate  exact  tones  will  be  lessened  and  the  voice 
become  harsher.  His  taste  will  also  be  disturbed, 
sometimes  showing  great  changes  and  often  ex- 
treme disgust  for  things  previously  pleasant;  or 
it  may  become  greatly  exaggerated,  and  display 
abnormal  longings  for  strange  flavors. 

The  occasional  narcotism  of  the  higher  brain, 
affecting  the  senses,  first  may  sometimes  increase 
their  acuteness  for  a  brief  period,  but  brain  power 
constantly  diminishes.  The  continued  use  of  opium 
perverts  the  normal  activities  of  its  functions. 
When  morphin  is  used  continuously,  the  nutrition 
and  appetite  show  perversions  which  may  extend 
to  active  delusions;  thus,  in  one  case  liquid  foods 
were  used  exclusively,  from  the  delusion  that  solid 
foods  were  always  burdensome  and  poisonous  to  the 
system. 

In  another  case  a  fish  diet  was  insisted  upon, 
the  subject  reasoning  that  all  other  diets  were  inju- 


Symptoms;  Prognosis;  Termination      109 

rious.  Great  varieties  of  food  perversions,  strange 
appetites  and  tastes  follow,  which  in  many  instances 
indicate  the  form  of  addiction  or  drug  taken. 

Next  to  the  sense  derangements  comes  the  damage 
to  the  higher  morals.  One  cannot  use  morphin  long 
without  suffering  from  weakened  and  obscure  ideas 
of  duty  and  right  relations  to  others.  Conceptions 
of  truth  and  discriminations  between  truth  and  false- 
hood become  more  and  more  cloudy.  Egotism, 
selfishness,  childish  prevarication,  and  inability  to 
act  along  rational,  consistent  lines  of  duty  and 
obligation  increase  rapidly  in  some  cases ;  in  others 
slowly.  In  all,  after  a  time,  there  are  marked 
changes. 

The  constant  narcotism,  besides  breaking  up  the 
accuracy  of  the  sense  impressions,  diminishes  the 
capacity  to  analyze  them.  The  brain  is  constantly 
receiving  inaccurate  information,  and  is  unable  to  dis- 
criminate and  act  wisely.  Untruthfulness,  a  decreas- 
ing sense  of  honor,  less  pride  of  character  afid  appear- 
ance, follow.  Forgetfulness  to  carry  out  promises, 
suspicion  of  wrong  from  others,  creduHty,  intrigue, 
with  delusions  of  ability  to  conceal  the  present 
condition  and  deceive  friends  and  associates,  all  are 
common  symptoms  of  the  degeneration  of  the  higher 
brain, 

A  sudden  change  of  character  is  significant  of 
some  profound  revolution  and  breaking  down  of  the 


I  lo  Morphinism 

nerve-centers.  A  man  previously  truthful  and 
honest  who  suddenly  falsifies  and  does  disreputable 
things  without  motive  may  be  expected  to  be  under 
the  influence  of  some  powerful  drug. 

A  business  man  who  displayed  great  changes  of 
character  was  judged  to  be  a  morphin-taker  by  his 
physician,  who  could  not  account  for  them  in  any 
other  way.  The  diagnosis  was  found  to  be  correct, 
although  at  the  time  there  were  no  other  reasons 
for  this  conclusion. 

The  failure  of  the  higher  ethical  brain  may  be 
said  to  be  a  pathognomonic  symptom,  occurring  in 
all  cases  of  morphinism,  sometimes  prominently  in 
the  early  stages;  in  others,  unnoticed  until  later, 
and  then  varying  in  degree  and  direction,  but  always 
present. 

(^Kleptomania  is  thought  to  be  one  of  the  most 
common  symptoms  of  this  change  in  the  morphin- 
ist. Very  startling  and  strange  cases  are  reported 
in  large  cities  among  persons  called  shoplifters,  who 

in  many  instances  are  users  of  this  drug.     There  are 
/■'  --^ 

;  in  all  large  cities  kleptomaniacs  among  women  of  the  ] 
\  '- 

\  better  class  who,  without  purpose  or  motive,  purloin 

anything  that  may  attract  their  attention.  Some- 
times their  thefts  show  great  cunning  and  adroit- 
ness; at  others,  they  are  stupid  and  bold. 

In  the  reported  cases  of  this  class  there  are  persons 
who  stole  only  paper  and  pencils ;  others  took  hand- 


Symptoms ;  Prognosis  ;  Termination      1 1 1 

kerchiefs ;  others,  knives  and  forks  and  napkin-rings ; 
others,  fans  and  perfumery  bottles  and  articles  of 
jewelry;  and  so  on  in  an  endless  procession.  Why 
they  should  simply  take  one  article  or  class  of  articles 
is  not  easily  explained.  These  stolen  goods  never 
brought  any  profit  by  being  sold  or  pawned,  but 
simply  were  taken  to  gratify  a  morbid  impulse  for 
possession.  Some  of  these  persons  boast  of  a  very 
high  ethical  character  and  show  great  alertness  and 
cunning  to  explain  their  inconsistent  conduct,  yet 
take  advantage  of  every  opportunity  to  deceive. 

A  writer  has  said  that  many  of  the  shoplifters 
among  women,  or  those  who  are  known  to  be  klepto- 
maniacs among  the  higher  walks  of  life,  are  found 
to  be  very  much  worse  at  the  menstrual  period,  and 
after  that  do  not  exhibit  these  peculiarities.  The 
wife  of  a  noted  physician,  who  used  morphin  irregu- 
larly, always  stole  books  for  the  first  two  or  three 
days  after  the  cessation  of  the  menstrual  period, 
and  could  not  recollect  where  she  had  been  or  what 
she  had  done.  When  convinced,  she  manifested 
extreme  penitence  and  sought  to  restore  or  pay  for 
the  stolen  goods.  No  efforts  of  an  attendant  could 
prevent  the  thefts  and  no  watching  could  outwit  the 
cimning  displayed. 

A  morphinist  under  the  writer's  care  during  the 
menstrual  period  displayed  great  cimning  in  procur- 
ing morphin  and  concealing  it.     She  did  not  use  it, 


112  Morphinism 

but  was  possessed  with  a  mania  to  get  it  secretly.  It 
was  found  to  be  useless  to  attempt  to  prevent  her 
tmless  she  was  locked  up.  Finally  she  was  not  re- 
strained at  this  time,  and  when  the  mania  was  over 
she  freely  gave  up  all  the  morphin  obtained  and 
described  the  means  of  procuring  it. 

A  very  able  man,  from  his  eccentricity  of  conduct 
suspected  of  taking  drugs,  was  found  to  have  dis- 
tinct periods  of  swindling  propensities,  during  which 
he  would  plan  and  execute  or  try  to  carry  out  schemes 
of  the  most  disreputable  nature.  His  associates  recog- 
nized that  he  was  not  sane  on  these  occasions,  and 
would  postpone  action  until  he  recovered  his  equilib- 
rium and  recognized  the  danger  of  his  schemes. 

A  number  of  morphinists  have  erotic  paroxysms 
of  a  few  days'  duration.  Their  conduct  during  this 
time  is  that  of  sexual  maniacs.  Rapes,  seductions, 
and  other  criminal  acts  occur,  sometimes  boldly,  or 
with  secretiveness  and  cunning.  When  coming 
under  legal  notice,  no  degree  of  morphin  addiction 
has  been  recognized,  and  yet  such  persons  are 
literally  imbeciles. 

Religious  manias,  speculative  manias,  political 
and  social  changes  of  opinions,  and  indorsement  of 
strange  theories  are  the  signs  of  mental  change  and 
of  the  presence  of  morphin,  especially  when  these 
conditions  alternate  or  are  variable. 

The   morphinist,  when   examined   carefully,  will 


Symptoms;  Prognosis;  Termination      113 

always  be  found  to  display  changes  of  conduct  and 
appearance  that  are  unaccountable  from  any  other 
cause.  His  habits  of  working,  sleeping,  eating,  and 
mental  activity  are  altered,  and  new  conditions 
come  on.  The  nights  are  passed  in  wakefulness. 
Sleep  comes  only  in  the  morning.  Sometimes  any 
monotonous  surroimdings  will  suggest  and  bring  on 
sleep,  as  in  the  case  of  old  people.  Excitement  of 
any  kind  is  followed  by  insomnia  and  vertigo. 
Sometimes  muscular  excitement  and  nervous  unrest 
demand  constant  action  and  movement.  At  other 
times  great  indisposition  to  move  or  stir  is  apparent. 

The  general  symptomatology  may  be  expressed  as 
resembling  tlTat  of  progressive  paralysis  confined 
largely  to  the  sense  organs,  the  brain,  and  its  higher 
functional  activities.  The  genital  functions  suffer. 
Impotence,  irritation,  priapism,  nymphomania,  and 
paralysis  of  the  sexual  fiuictions  are  more  or  less 
common. 

The  anesthesia  alternating  with  hyperesthesia 
beginning  at  the  sensory  centers  extends  to  the 
higher  brain  and  merges  into  paralysis  to  a  certain 
degree  after  a  time.  Sometimes  it  is  very  pro- 
nounced in  delusive  egotism;  at  others,  in  melan- 
cholia; at  others,  in  depression  and  dementia. 

The  complications  are  niunerous,  resulting  in  a 
wide  variation  of  symptoms  and  progress.  The 
heart  becomes  functionally  deranged  and  asthmatic 


114  Morphinism 

states  come  on.  Catarrhal  states  and  hoarseness 
are  common.  Acute  bronchitis,  pneumonia,  or 
nephritis  may  suddenly  appear,  usually  ending 
fatally.  Abscesses  where  the  needle  has  been  used 
develop  into  erysipelatous  states  and  death.  Acute 
inflammations  are  always  impending  and  likely  to 
break  out  at  any  time. 

Notwithstanding  these  perilous  symptoms,  a  cer- 
tain number  of  morphinists  live  to  advanced  age, 
and  although  suffering  from  impaired  health  and 
general  feebleness,  seem  to  evade  the  ordinary  con- 
sequences of  this  poison.  Others,  realizing  their 
position,  make  frequent  struggles  to  escape,  giving 
up  the  drug  for  a  short  time,  then  returning  to  it, 
always  full  of  hope  that  they  will  be  able  to  live 
without  it,  yet  continually  relapsing,  and  finally 
dying  from  some  intercurrent  disease. 

Notwithstanding  the  fact  that  the  symptoms  may 
vary  widely,  according  to  the  conditions  of  living, 
predispositions  both  inherited  and  acquired,  there  is 
generally  a  uniform  line  of  progress  which  may  be 
traceable  in  each  case.  No  efforts  at  concealment 
can  last  long.  Certain  symptoms  distinguishable 
by  the  expert  diagnostician  are  rarely  absent,  and 
while  it  may  not  be  possible  always  to  verify 
them,  yet  a  careful  study  of  the  patient's  daily 
life  and  history  will  often  give  ample  confirma- 
tion. 


Symptoms ;  Prognosis ;  Termination      1 1 5 

When  morphin  is  removed  a  great  variety  of  very 
complex  symptoms  appear.  Often  some  symptoms, 
prominent  before,  become  intensified  and  greatly 
exaggerated,  or  new  ones  appear.  In  all  this  there 
is  profound  anemia  and  nerve  exhaustion,  which 
may  be  constant  or  in  other  cases  vary  from  week 
to  week,  demanding  persistent  watchfulness. 

It  not  infrequently  happens  that  secret  morphin- 
takers  suddenly  abandon  the  use  of  the  drug,  and 
the  physician,  not  knowing  this  fact,  is  puzzled  at 
the  complex  symptoms.  The  patient  is  under  a 
strain  to  conceal  the  causes,  and  not  infrequently 
phenomenal  cases  are  reported  in  which  the  morphin 
addiction,  if  known,  would  clear  up  the  mystery. 

In  the  withdrawal  symptoms  there  are  both 
physical  and  psychic  elements  which  must  be 
recognized.  The  one  is  directly  due  to  abstinence 
and  irritation  following  the  withdrawal  of  the 
morphin;  the  other  is  very  largely  based  on  the 
memory  of  the  pain  which  morphin  was  first  taken 
to  remove.  The  latter  condition  is  rarely  recog- 
nized, but  it  can  be  seen  very  distinctly  in  many 
cases  during  the  withdrawal  period. 

If  the  morphin  was  first  used  to  combat  the 
suffering  from  insomnia,  this  symptom  will  become 
most  prominent  in  the  withdrawal  stage.  If  used 
first  for  neuralgias,  local  or  general,  or  dyspepsias 
or  degrees  of  exhaustion,  these  conditions  reappear 


1 16  Morphinism 

plus  the  damage  to  the  nerve-centers  from  the 
continuous  addiction. 

The  exhaustion  from  sexual  excess  which  pro- 
voked the  use  of  morphin  is  not  infrequently  fol- 
lowed after  its  removal  by  a  sexual  delirium  with 
the  same  exhaustion.  No  matter  how  long  the  mor- 
phin may  have  been  used,  the  causes  for  which  it 
was  first  taken  remain,  and  frequently  appear  when 
the  narcotism  is  taken  away. 

In  morphinism  two  extreme  conditions  follow  each 
other:  one  of  anesthesia,  and  the  other  of  hyperes- 
thesia. The  latter  is  very  prominent  as  a  result  of 
the  removal  of  the  drug,  and  is  always  associated 
with  sensory  defects.  It  is  this  stage  of  hyperes- 
thesia following  the  withdrawal  in  which  dreams  both 
horrid  and  pleasurable  occur,  and  with  exaggerated 
and  confused  sense  perceptions.  In  some  cases  this 
condition  becomes  intensified  up  to  the  stage  of 
mania  of  a  painful  form. 

Another  psychic  phase  is  the  delusion  of  will-power 
to  control  the  body.  Such  persons  are  practically 
victims  of  paralysis  of  the  will  without  being  con- 
scious of  it.  Experience  teaches  them  nothing. 
They  still  believe  in  their  ability  to  control  them- 
selves. 

Notwithstanding  this  hyperesthesia,  the  intellec- 
tual faculties  may  show  little  change  and  the  con- 
duct along  automatic  lines  may  be  practically  the 


Symptoms;  Prognosis;  Termination      117 

same  as  before.  The  want  of  decision  and  irreso- 
lution may  be  concealed,  and  only  appear  along 
lines  of  new  personalities.  When  morphin  is  taken 
again,  the  defects  of  will  and  conduct  may  sud- 
denly disappear  and  all  the  old  vigor  apparently 
return. 

Thus,  in  one  case,  a  clergyman  who  occupied  a 
prominent  place  was  at  times  considered  by  his 
intimates  to  be  insane.  These  insane  attacks 
would  be  followed  by  periods  of  great  mental  clear- 
ness, in  which  his  sermons  and  intellectual  work 
were  equal  to  those  of  any  time  of  his  life.  Except 
a  slight  pallor  and  loss  of  pride  of  appearance,  noth- 
ing could  be  noticed.  He  was  a  morphin-taker, 
and  these  periods  of  mental  aberration  followed  the 
hyperesthetic  state  from  abstinence  from  morphin. 
At  times  the  pulse  was  intermittent,  the  heart's 
action  weak,  and  dyspnea  with  hoarseness  was 
especially  marked.  The  eyes  lost  their  brightness 
and  the  face  its  power  of  expression;  the  skin  had 
an  earthy  look.  All  this  would  change  in  a  brief 
time  and  his  former  vigor  would  come  on.  These 
strange  periods  of  insanity  and  great  mental  activity 
were  due  to  his  secret  efforts  to  give  up  the  drug, 
and  his  failure  and  relapse  to  its  use  again.  Sudden 
changes  of  this  nature  suggest  the  use  of  morphin 
or  other  narcotic  drugs. 

The  presence  of  delusions  and  hallucinations  is 


1 1 8  Morphinism 

certain  to  follow  in  all  cases,  although  sometimes 
not  so  prominently  noticed  as  in  other  insanities. 
References  will  be  made  to  these  in  the  chapter  on 
medicolegal  considerations.  The  most  common  of 
all  the  delusions  that  have  been  mentioned  are  those 
of  the  harmlessness  of  the  addiction  and  of  the 
ability  to  stop  at  any  time,  and  when  these  delusions 
are  exposed,  they  are  explained  by  external  influences 
over  which  the  patients  have  no  control. 

Other  delusions  have  reference  to  the  injustice 
of  their  friends  and  the  failure  to  recognize  their 
real  condition,  the  effect  of  which  is  to  precipitate 
them  into  worse  states.  The  delusions  are  largely 
false  reasonings,  built  up  from  the  erroneous  sense 
impressions,  and  perverted  conceptions  of  their  own 
conditions  and  surroundings. 

In  some  instances  very  marked  delusions  of  the 
infidelity  of  wives  or  husbands,  and  the  dishon- 
esty of  the  persons  with  whom  they  have  business 
relations,  are  present.  Often  these  very  delusions 
have  a  basis  in  their  own  conduct.  Men  and  women 
who  are  unfaithful  are  positive  that  others  are 
deceiving  in  the  same  way.  Those  who  are  dis- 
honest themselves  look  with  suspicion  upon  every- 
body else. 

Some  of  the  hallucinations  are  less  marked,  and 
more  frequently  are  concentrated  on  minor  objects, 
such  as  voices  at  night,  which  keep  them  awake, 


Symptoms ;  Prognosis  ;  Termination      1 1 9 

and  sounds  of  passing  persons  who  wish  to  annoy 
them,  or  the  effect  of  drugs  which  have  prevented 
them  from  seeing  or  hearing  properly.  They  are 
nearly  always  confined  to  petty  acts  of  persecution. 
Many  examples  of  these  will  be  found  in  the  "Jour- 
nal of  Inebriety." 

One  quite  prominent  incident  excited  a  great  deal 
of  interest  in  a  large  city.  A  physician  of  promin- 
ence began  to  write  slanderous  notes  under  assumed 
names  to  persons  he  supposed  to  be  his  enemies. 
This  was  continued  for  nearly  a  year,  creating  im- 
mense excitement  and  disgust.  Finally  the  author 
was  revealed,  but  stoutly  denied  all  compHcity.  He 
was  a  morphin-taker,  and  this  was  simply  a  delu- 
sional state  taking  on  the  form  of  slander. 

The  boasted  strength  and  extreme  indignation  man- 
ifest when  doubts  are  mentioned  are  quite  common 
among  the  better  class  of  morphinists.  An  instance  is 
that  of  a  clergyman  whose  egotism  both  in  and  out 
of  the  pulpit  grew  more  and  more  offensive.  When 
remonstrated  with,  he  considered  it  persecution, 
and  acted  more  and  more  defiantly.  Finally  he 
was  taken  with  acute  pneumonia,  went  to  a  hospital, 
and  his  morphinism  was  discovered. 

Often  the  strange  political,  sociologic,  and  moral 
theories  urged  by  persons  of  previous  good  judgment 
and  character  are  explained  by  finding  them  to 
be  morphinists.     Radicals  and  extremists  who  are 


1 20  Morphinism 

bold  to  recklessness,  and  then  suddenly  subside  and 
fail  to  make  their  actions  consistent,  often  appear  as 
drug-takers  after  a  time. 

Usually  the  morphinist  is  not  a  leader  or  in- 
novator in  any  department  of  work  or  thought. 
He  may  be  a  critic  and  doubter,  but  he  rarely  takes 
an  active  part  in  any  original  work.  The  increasing 
anesthesia  from  the  drug  makes  him  more  and  more 
disinclined  to  active  participation  in  public  affairs 
and  more  anxious  for  retirement  and  seclusion,  yet 
in  the  early  stages  strange,  erratic  courses  of  conduct 
may  be  a  marked  peculiarity.  The  following  is  a 
typical  case,  illustrating  the  general  symptoms  of 
morphinism : 

A.  B.,  a  lawyer,  temperate  and  well  up  to  forty 
years  of  age,  without  any  history  of  heredity,  be- 
came disappointed  at  the  failure  of  his  election  to 
a  public  office.  A  period  of  invalidism  followed, 
ending  in  his  becoming  a  secret  morphinist.  For 
five  years  he  followed  his  profession  with  indus- 
try and  energy,  but  his  conduct  changed.  He  was 
less  reliable,  and  was  either  very  brilliant  or  stupid, 
He  displayed  great  energy  over  unimportant  trifles 
and  was  indifferent  to  graver  matters.  He  was 
harsh  in  his  family  relations  at  times  and  over- 
indulgent  at  others.  Sometimes  he  would  go  away 
for  a  week  unexpectedly,  apparently  wandering 
rotmd  without  purpose  or  motive,  then  returning, 


Symptoms  ;  Prognosis ;  Termination      121 

giving  frivolous  excuses  for  his  absence  and  dis- 
playing for  a  time  great  energy  of  mind  and  body. 
His  memory  failed  him  and  he  frequently  took  false 
positions  in  court  on  questions  of  law,  and  when 
proved  to  be  in  the  wrong,  persisted  in  explaining  his 
mistake  in  some  strange  way.  His  appetite  failed, 
his  sleep  was  broken,  and  his  irritability  increased. 
His  addiction  to  morphin  was  exposed  and  his 
friends  remonstrated  with  him  to  no  purpose.  He 
became  egotistical,  was  confident  that  he  could  stop 
at  any  time,  and  believed  his  condition  was  aggra- 
vated by  the  faults  of  his  friends  and  surroimdings. 
He  refused  to  take  any  medicine,  and  when  at  times 
it  was  difficult  for  him  to  procure  morphin,  would  use 
spirits.  His  manner  changed.  He  became  rough, 
coarse,  abrupt,  careless  in  dress  and  slovenly  in 
appearance,  avoided  company,  and  was  irritable 
when  opposed  and  unreliable  in  his  promises.  He 
lost  business  and  friends  and  fell  into  disreputable 
ways,  and  was  finally  arrested  for  forging  pension 
papers.  The  sentence  was  suspended  on  his  promise 
to  go  under  treatment  in  an  asylum.  The  morphin 
was  removed.  He  was  discharged,  but  a  year  later 
relapsed  and  became  demented,  and  was  returned  to 
the  asylum. 

This  illustrates  many  of  the  prominent  features 
in  the  symptomatology  of  these  cases. 

The  second  example  is  given  to  show  some  of 


122  Morphinism 

the  more  obscure  symptoms  which  occur  among 
the  cultured  classes.  An  eminent  teacher  and 
president  of  a  college,  while  doing  some  research 
work  in  the  far  West,  contracted  malaria,  and  was 
an  invalid  for  several  months.  There  is  no  doubt 
that  he  began  the  secret  use  of  morphin  about  this 
time.  For  several  years  his  changing  manners  and 
disregard  of  personal  appearance  attracted  some 
attention.  He  seemed  careless  and  forgetful  of  his 
promises,  and  from  being  an  open,  frank  man  be- 
came secretive  and  suspicious.  His  family  physi- 
cian diagnosed  neurasthenia,  and  treated  him  elabor- 
ately, advising  rest  and  change.  Disorders  of  diges- 
tion and  sleep,  associated  with  stages  of  irritation 
and  strange  indifference  amounting  to  exhaustion 
and  stupor,  alternated  with  each  other.  He  would 
not  allow  massage  to  be  practised  or  the  application 
of  electricity  except  over  his  clothing.  When  the 
physician  insisted  on  a  physical  examination  of  his 
abdomen,  he  refused,  giving  the  most  frivolous 
excuses.  At  times  his  eye  was  flashing  and  brilliant, 
then  there  would  be  periods  of  dulness  in  which  he 
would  be  half  asleep.  This  condition  continued  for 
a  long  time,  no  one  suspecting  the  real  cause.  In 
the  interval  he  went  abroad,  visited  watering- 
places,  and  took  special  courses  of  treatment.  One 
physician  diagnosed  paresis ;  another,  serious  mental 
trouble;  all  agreed  that  he  had  cerebrasthenia  and 


Symptoms;  Prognosis;  Termination      123 

neurasthenia.  At  length  he  resigned  from  his  col- 
lege and  went  to  live  in  the  country,  where  by  an 
accident  the  supply  of  morphin  gave  out  and  the  with- 
drawal symptoms  precipitated  him  into  semi-mani- 
acal conditions  which  were  treated  by  morphin ;  and 
the  diagnosis  of  morphinism  was  made  by  a  country 
physician.  The  mania  subsided,  but  he  continued 
the  use  of  morphin  until  his  death  a  few  years  after- 
ward. His  ability  to  conceal  and  explain  his  un- 
toward symptoms  baffled  all  the  physicians  he  was 
brought  in  contact  with,  with  one  exception. 

A  third  example  brings  out  some  very  unusual 
symptoms  in  the  progress  of  a  case  which  serve  to 
illustrate  another  phase  of  these  obscure  diseases.  A 
widow,  a  leader  in  society  and  prominent  for  her 
intelligence  and  culture,  was  overwhelmed  with 
grief  at  the  death  of  her  favorite  son.  The  insomnia 
and  suffering  which  followed  were  treated  by  the 
attending  physician  with  morphin  by  the  needle. 
She  seemed  to  recover  and  the  morphin  was  aban- 
doned by  the  physician.  Probably  from  this  time 
she  continued  its  use  secretly.  After  a  period  of 
prolonged  travel  she  returned,  and  manifested  ex- 
traordinary interest  in  church  and  philanthropic 
work,  visiting  the  sick  and  leading  prayer-meetings, 
showing  great  fervor  and  religious  devotion.  This 
was  so  unusual  as  to  attract  attention.  She  was 
found  to  be  impulsive  and  erratic.     After  lying  in 


124  Morphinism 

bed  for  a  day  or  two,  she  would  have  a  period  of  an 
equal  length  of  time  in  which  she  would  be  very 
energetic  in  religious  work,  then  claim  exhaustion 
and  be  secluded  in  her  home  for  a  time.  Her  con- 
duct grew  more  and  more  inconsistent.  She  was 
forgetful  of  her  promises  and  denied  things  which 
she  had  done  a  day  or  two  previously ;  was  suspicious 
of  those  about  her,  and  at  times  manifested  great 
irritability,  then  extreme  penitence  and  sorrow.  To 
her  family  she  became  more  distant  and  uncertain 
— sometimes  rarely  speaking ;  then  very  effusive  and 
anxious  about  their  interests.  She  spent  a  great 
deal  of  time  in  her  room.  She  adopted  the  Seventh 
Day  Baptist  theories  and  believed  in  the  sudden 
early  coming  of  the  end  of  the  world.  With  her 
clergyman  she  was  contentious  and  strangely  incon- 
sistent. To  the  family  physician  she  was  skeptical, 
and  would  not  take  medicines.  This  condition  of 
erratic  religious  emotionalism  continued  for  five 
years,  while  the  mental  disturbances  increased  and 
her  appearance  grew  more  and  more  wretched. 
Finally  she  was  taken  to  a  sanatorium,  when  her 
real  trouble  was  discovered.  In  all  these  years  she 
had  used  morphin  with  the  needle  in  small  doses 
and  had  been  able  to  conceal  it  from  her  family  and 
friends. 

Example  fourth  is  more  prominent,  and  probably 
more  common  in  the  ordinary  experience  of  life.     A 


Symptoms;   Prognosis;  Termination      125 

merchant  who  had  used  wine  on  the  table  for  many 
years,  abstaining  at  all  other  times,  became  ill  from 
acute  indigestion,  and  was  given  morphin  by  the 
needle.  The  trouble  continuing,  the  physician  pro- 
cured a  needle  for  him  and  taught  him  how  to  use 
it  when  suffering.  He  abandoned  all  use  of  spirits 
and  very  soon  exhibited  marked  changes  of  appear- 
ance. His  dress  was  slovenly  and  his  manners  care- 
less, and  his  former  pride  declined.  He  became 
untruthful,  allowed  his  notes  to  go  to  protest,  neg- 
lected his  business,  and  claimed  that  these  faults 
were  due  to  others;  was  extremely  parsimonious  at 
times  and  credulous.  He  engaged  in  several  busi- 
ness schemes  that  were  failures.  He  claimed  all  the 
time  that  he  was  perfectly  well,  and  had  no  pains  or 
aches.  His  habits  of  sleeping  and  eating  were  irregu- 
lar, and  he  frequently  disappeared  on  apparently 
aimless  joiimeys.  On  one  occasion  his  leg  was 
broken,  and  he  was  taken  to  a  hospital,  where  his 
morphin  addiction  was  discovered.  From  this  time 
on,  all  efforts  at  concealment  were  abandoned.  He 
used  morphin  daily,  became  an  intriguer,  lost  his 
property  and  reputation.  He  made  several  efforts 
to  recover  in  different  asylums,  but  relapsed  soon 
after  leaving,  and  finally  died. 

In  these  four  cases  the  general  symptoms  of  mor- 
phinism are  outlined.  When  morphin  is  abandoned 
for  opium,  the  concealment  is  less  prominent.     The 


126  Morphinism 

effects  of  opium  are  more  of  a  narcotic  than  those  of 
morphin,  and  the  stupor  and  changed  conditions 
are  more  apparent.  The  irritation  and  exaltation 
seen  in  morphinists  is  seldom  marked  in  opium 
patients.'  Hence  a  disposition  to  stupor  is  a  sig- 
nificant symptom  of  opium-taking.  All  the  symp- 
toms taken  together  are  essential  to  determine  the 
probable  causes,  and  no  one  symptom  is  to  be  relied 
upon. 

The  variations  noticed  in  the  symptomatology  of 
morphin  cases  are  due  to  idiosyncrasies  of  the  indi- 
vidual and  of  the  surroundings,  training,  occupa- 
tion, and  purposes  in  life.  In  one  with  a  previously 
defective  brain  the  action  of  morphin  will  often 
conceal  the  defects  or  intensify  them.  When  one 
is  bom  with  a  feeble  ethical  brain  and  is  deficient  in 
self-control,  the  effects  of  morphin  will  differ  from 
those  of  a  person  who  had  a  large  development  of 
the  high  moral  brain. 

The  petty  criminality  and  deception  so  common 
among  the  lower  classes  who  use  morphin  no  doubt 
have  a  basis  in  early  paralysis  or  defect  of  the  higher 
brain.  Many  of  the  peculiarities  of  conduct  and 
thought  may  have  had  an  early  physical  basis  of 
defect  which  the  morphinism  intensified  and  brought 
out. 

The  strange  peculiarities  which  appear  in  a  large 
number  of  cases  are  no  doubt  often  traceable  to 


Symptoms;  Prognosis;  Termination      127 

organic  defects;  at  all  events,  these  strange  delu- 
sions, impulses,  and  insanities  show  peculiar  psycliic 
and  physical  disorganization.  How  far  the  re- 
moval of  morphin  will  change  these  conditions  and 
restore  the  original  condition  of  health  and  vigor  is 
still  an  unsettled  question. 

From  an  examination  of  a  large  number  of  per- 
sons there  are  traces  of  a  uniform  movement  and 
general  symptomatology  following  certain  lines 
which  are  very  apparent  in  many  cases.  In  all 
probability  after  the  first  five  years  of  morphin  addic- 
tion conditions  of  chronicity  are  established  which 
lessen  the  chances  of  recovery.  The  second  five 
years  in  the  progress  increases  the  chronicity,  and 
usually  ends  in  death  or  insanity  and  stages  of 
dementia.  This  dates  from  the  time  when  morphin 
was  first  used  continuously. 

It  is  asserted  by  some  writers  that  ten  years  of 
the  continuous  use  of  morphin  without  break  or 
change  makes  the  case  a  fatal  one,  death  following 
from  exhaustion  and  acute  intercurrent  diseases.  In 
reality  very  few  cases  use  morphin  regularly  in  in- 
creasing doses  so  long  as  eight  or  ten  years.  There 
are  generally  breaks  and  halts  and  efforts  to  aban- 
don the  morphin  or  to  substitute  some  other  drug 
for  it.  Many  persons  use  morphin  in  small  and 
irregular  doses  depending  upon  conditions  of  pain 
or  temporary  distress.     Used  in  this  way,  the  addic- 


128  Morphinism 

tion  may  go  on  for  a  long  time  and  may  not  increase 
to  large  doses  unless  the  patient  is  past  middle  life. 

When  the  addiction  has  extended  beyond  eight  or 
ten  years,  the  future  becomes  more  and  more  uncer- 
tain. A  sudden  mania  may  supervene  and  the  mor- 
phin  may  be  given  in  continuous  narcotic  doses 
until  the  brain  gives  way.  Many  of  these  cases  be- 
come opium-smokers,  finding  the  narcotism  from 
opium  more  pleasing  and  lasting  longer,  hence  they 
turn  to  it. 

If  the  stomach  is  not  disturbed,  the  addiction 
may  go  on  for  years.  If  alcohol  is  substituted,  the 
mental  disturbance  increases  and  the  possibility  of 
pneumonia  and  nephritis  is  increased. 

It  may  be  said  in  a  general  way  that  few  morphin 
habitues  live  longer  than  ten  or  fifteen  years  after 
the  beginning  of  the  addiction.  Most  of  them  die 
in  about  ten  years.  Others,  from  changes  and 
breaks  in  its  use  and  efforts  to  recover,  go  on  a  little 
longer. 

A  certain  number  suffer  from  general  marasmus 
and  die  from  exhaustion.  Others  become  de- 
mented and  develop  ascites,  nephritis,  and  die.  A 
certain  number  suffer  from  paralysis  before  death, 
usually  of  the  extremities,  followed  by  heart  failure. 
In  some  cases  sudden  coma,  apparently  due  to  mor- 
phin, ends  fatally.  In  these  cases  there  is  present 
some  form   of   autointoxication,   which,  added    to 


Symptoms;  Prognosis;  Termination      129 

that  of  the  morphin,  increases  its  toxic  effects  on 
the  heart  and  brain-centers. 

If  alcohol  has  been  associated  with  morphin,  neu- 
ritis, rheumatism,  and  blood  diseases  sometimes  ap- 
pear at  the  termination  of  the  case.  Hemorrhage  is 
not  often  noticed,  except  where  there  is  fatty  heart 
and  a  tendency  to  arthritis. 

The  few  cases  that  go  beyond  fifteen  years  show 
decided  signs  of  extreme  age  and  degeneration. 
Sudden  death  is  a  common  termination,  usually  from 
heart  failure.  Stories  of  morphinists  living  to  old 
age  are  seldom  confirmed,  but  instances  of  persons 
who  alternate  the  use  of  opium  and  morphin  with 
spirits  and  have  free  intervals  of  uncertain  dura- 
tion are  noted. 

The  general  anemic  and  hysteric  symptoms  can- 
not be  mistaken.  The  profound  failure  of  what  is 
called  the  higher  moral  brain  is  always  a  most  sig- 
nificant symptom.  Untruthfulness,  loss  of  all  moral 
consideration  and  sense  of  duty  to  others,  with  in- 
tense selfishness,  are  characteristic  symptoms.  The 
more  degenerate  in  this  respect,  the  more  emphatic 
will  be  the  claims  of  honor  and  morality.  No  state- 
ment by  the  patient  of  his  condition  and  purposes  can 
be  trusted,  no  matter  what  the  motives  may  be.  To 
this  there  are  exceptions,  but  they  only  prove  the  rule. 

A  certain  number  of  morphin-takers  after  an  ex- 
perience of  frequent  withdrawal  and  relapses  have 
9 


1 30  Morphinism 

a  delusion  of  being  beyond  all  possibility  of  re- 
lapse. From  the  depression  which  existed  before, 
they  go  to  the  other  extreme,  and  indulge  in  the 
most  credulous  expectations  of  never  using  the  drug 
again.  If  in  company  of  persons  of  similar  charac- 
ter, they  receive  new  exaltations  and  are  more 
sanguine  and  positive.  . 

In  some  instances  they  enjoy  posing  as  reformed 
and  restored  morphinists  whose  former  life  was  filled 
with  wretchedness  and  misery,  and  who  now  have 
gone  to  the  other  extreme  of  vigor,  contentment, 
and  happiness.  Persons  who  have  used  alcohol  as- 
sociated with  the  morphin  often  become  vociferous 
reformers,  and  their  very  positiveness  is  suspicious. 
Such  men  are  found  about  sanatoriums,  on  the 
streets,  and  in  public  places,  at  reform  meetings, 
proclaiming  loudly  and  emphatically  their  escape, 
and  boasting  of  the  means  which  they  used. 

This  class  have  become  prominent  as  managers 
and  supporters  of  the  "gold  cure"  asylums  and  the 
secret  drugs  to  break  up  morphinism.  After  a  time 
they  disappear,  relapsing  to  the  old  addiction. 
Sometimes  some  of  these  persons  recover  and  appear 
again  in  public,  but  of  the  morphinomaniacs  only  a 
few  ever  pose  for  reputation  and  public  notice  more 
than  once  or  twice.  The  degeneracy  which  accom- 
panies their  relapse  is  so  intense  that  recovery  rarely 
lasts  for  any  length  of  time. 


Symptoms;  Prognosis;  Termination      131 

Some  of  these  persons  resort  to  other  drugs,  and 
appear  in  sanatoriums  as  habitues  of  some  new  nar- 
cotic. Some  of  the  coal-tar  derivatives  have  been 
foimd  to  take  the  place  of  morphin,  and  been  used 
to  excess,  and  generally  with  bad  results.  The  treat- 
ment of  all  such  cases  by  narcotics  is  very  likely 
to  create  a  new  drug  addiction. 

The  following  is  an  example  of  a  drug  neurotic: 
Beginning  the  use  of  spirits  at  eighteen,  at  twenty 
the  subject  was  a  morphinist;  later  he  was  a 
cocain- taker ;  then  he  turned  to  alcohol  and  chloro- 
form, and  finally  to  opium  smoking  and  the  use  of 
paraldehyd  and  antipyrin.  From  each  of  these  ad- 
dictions he  claimed  to  be  permanently  cured.  He 
has  posed  on  several  occasions  as  an  example  of 
the  value  of  this  or  that  method  of  treatment.  He 
has  been  connected  with  two  empiric  "gold  cures," 
and  is  a  promoter  of  specific  drugs  of  this  class,  and 
a  public  lecturer  and  philanthropist  in  name. 

Not  infrequently  patients  who  have  used  morphin 
for  some  time  will  have  hallucinations  and  delusions 
of  persons  coming  into  their  room  at  night  and 
threatening  them,  or  of  voices  heard  through  the 
open  door  planning  schemes  for  their  injury,  or 
perhaps  the  nurse  in  her  efforts  to  adjust  the  bed  or 
pillow  will  be  charged  with  having  struck  or  tried 
to  injure  the  patient.  Such  patients  will  complain 
of  ill  treatment  and  insults  from  certain  members  of 


132  Morphinism 

the  family  or  from  persons  outside.  If  the  needle 
is  used,  fears  of  poisoning  will  be  entertained,  of 
syphilis  being  injected,  or  of  other  means  taken  to 
destroy  them.  The  use  of  the  needle  from  entirely 
mental  causes  and  the  anticipation  of  pain  may 
produce  nausea.  The  imagination  will  become  very 
vivid,  not  only  about  personal  matters,  but  con- 
cerning events  outside.  Such  persons  are  j)sycho- 
paths,  and  are  on  the  border-lines  of  insanity,  and 
always  complaining  of  conditions  outside  of  them- 
selves. Everything  is  objective  and  should  be  dif- 
erent.  Manias  and  phobias  and  defects  of  the  senses 
and  reasoning  are  common.  These  symptoms  point 
to  morphinism,  and  may  be  the  leading  ones  which 
indicate  mental  change. 


CHAPTER  V 
DIAGNOSIS;  PROGNOSIS;  COMPLICATIONS 

The  Eye.  The  Voice.  The  Manner.  The  Skin.  The  Appetite. 
Some  Means  of  Diagnosis.  Changes  in  Appearance.  Egotism. 
The  Prognosis.  Conditions  Which  Determine  This.  Sudden 
Changes.  Relapses.  Other  Drug-taking.  Detection  in  the  Urine. 
Washing  Out  the  Stomach.     Examples. 

Notwithstanding  the  uniformity  of  many  symp- 
toms, there  are  frequent  exceptions,  and  the  physi- 
cian must  be  prepared  for  these  if  he  would  make  an 
accurate  diagnosis.  The  common  symptoms  of  ane- 
mia and  pallor  are  wanting  in  some  cases.  Emacia- 
tion may  be  absent.  The  person  may  appear  to  be 
increasing  in  flesh,  and  his  skin  ruddy  and  clear. 

The  small  pupil  is  not  pathognomonic.  As  else- 
where stated,  often  morphinists  combine  atropin  or 
belladonna,  which  prevents  the  diminished  size  of 
the  pupil,  and  in  some  instances  gives  brilliancy  and 
clearness  to  the  eye. 

The  supposed  nervousness  does  not  occur  in  all 
cases,  and  is  not  noticeable  unless  the  amount  of 
morphin  is  reduced.  Some  persons  seem  serene  and 
placid  and  in  no  way  nervous  or  disturbed.  They 
will  seek  periods  of  retirement  in  which  they  will 

133 


134  Morphinism 

wish  to  be  alone  a  few  moments,  giving  very  plausi- 
ble reasons. 

The  eye  may  sometimes  seem  a  little  different  in 
the  peculiar  stare  and  fixedness  of  gaze,  and  in  per- 
sons who  are  habitues  of  long  standing,  the  conjunc- 
tivae will  show  signs  of  congestion.  Sometimes  the 
voice  changes.  When  the  system  is  saturated  with 
morphin,  the  voice  will  have  a  soft,  husky  tone. 
When  the  morphin  passes  away,  the  tone  will  be 
stridulent  and  sharp.  Many  of  these  cases  suffer 
from  itching  of  the  skin  and  also  of  the  nose. 

The  appetite  will  vary.  In  some  instances  it  will 
be  capricious  for  a  time,  and  the  patient  will  com- 
plain of  indigestion.  Disturbances  of  the  bowels 
are  also  significant  signs.  Periods  of  activity,  fol- 
lowed by  extreme  lassitude  and  fitful  sleep,  are  also 
frequent  indications.  In  the  chronic  cases,  night- 
sweats,  cold  and  hot  flashes  passing  up  and  down 
the  spine,  tremors,  and  restlessness  are  apparent 
when  the  dose  is  diminished. 

When  alcohol  is  combined  with  opium,  the  symp- 
toms become  more  complex  and  the  diagnosis  is 
more  often  that  of  alcoholism.  The  statement  of 
the  patient  is  not  to  be  regarded  as  reliable,  but  if 
the  morphin  is  used  by  the  needle,  the  marks  on  the 
body  are  unmistakable  signs. 

As  a  rule,  the  diagnosis  can  be  made  by  exclusion, 
but  this  necessitates  very  accurate  study  of  the  cir- 


Diagnosis;  Prognosis;  Complications     135 

cumstances  and  conditions  of  life  and  surroundings 
of  the  patient;  also  the  habits,  occupation,  and 
methods  of  thought,  and  these  will  always  be  open 
to  revision  and  change.  When  the  patient  denies 
all  use  of  the  drug,  the  diagnosis  must  be  a  matter  of 
inference  and  probable  conclusion  from  facts  which 
cannot  be  explained  in  any  other  way. 

When  the  use  of  morphin  is  concealed  and  the 
person  is  determined  to  keep  up  this  concealment 
from  others,  many  curious  symptoms  will  be  seen. 
The  eye  will  often  show  marks  of  this  condition  in  its 
instability  and  changeableness,  and  when  the  mor- 
phin is  withdrawn  have  the  appearance  of  suffering, 
or  seem  defiant  and  suspicious.  The  facial  expres- 
sions will  change  rapidly. 

It  is  said  that  frequent  cups  of  strong  coffee  taken 
by  a  concealed  morphinist  will  reveal  his  addiction  in 
the  dilated  eye  and  nervous  trembling  which  follow. 
After  the  effect  of  the  coffee  begins  to  disappear,  and 
with  it  the  narcotism  of  the  morphin,  a  sense  of  alarm 
will  be  manifest  in  the  manner  and  expression. 

A  physician  claims  to  be  able  to  make  a  diagnosis 
by  watching  the  effects  of  the  injection  of  small 
doses  of  morphin.  If  the  characteristic  symptoms 
do  not  follow,  he  concludes  at  once  that  it  is  a  case 
of  this  addiction.  When  injections  of  water  are 
given  and  the  patient  believes  it  to  be  morphin,  the 


136  Morphinism 

later  symptoms  of  uneasiness  and  restlessness  reveal 
the  condition. 

Probably  the  most  significant  signs  are  the  emo- 
tional changes,  such  as  irritability  or  unreasonable 
mental  disturbance  with  nervousness,  followed  by 
quiet  serenity  and  rest.  When  morphin  has  been 
used  at  first  to  relieve  some  neuralgic  condition,  and 
later  taken  secretly  and  constantly,  there  is  often 
hysterical  reproduction  of  the  early  causes,  which 
can  be  detected  by  a  careful  study. 

The  changes  in  personal  appearance,  loss  of  pride 
of  character,  indifference  to  obligation  and  duty, 
together  with  a  physical  ageing  in  appearance,  also 
the  shoulders  bent  forward  and  the  walk  and  air  of  a 
person  rapidly  growing  old,  are  significant  symp- 
toms. 

When  the  skin  is  not  livid,  it  may  become  dis- 
colored and  have  a  chocolate  appearance.  General 
anemia,  with  changed  tone  of  voice,  are  significant. 
A  most  common  diagnostic  symptom  is  the  absence 
of  emotional  muscular  movements  of  the  face,  fol- 
lowed by  the  other  extreme  of  great  play  of  the 
facial  muscles. 

No  accurate  diagnosis  can  be  made  from  a  single 
examination,  although  careful  questioning  of  a  con- 
cealed morphinist  will  very  often  reveal  his  condition 
in  his  incautious,  unthinking  efforts  to  explain  it. 
The  childish  prevarication  and  fooHsh  sensitiveness 


Diagnosis;  Prognosis;  Complications     137 

to  appear  well  always  excite  suspicion  and  often 
indicate  unmistakably  the  real  condition.  The 
morphinist,  with  all  his  cunning  and  intrigue,  lacks 
consistency  and  steadiness  in  both  conduct  and  men- 
tal operations,  and  in  this  way  he  often  betrays  him- 
self. 

In  the  later  stages  the  defects  of  reason  and  com- 
parison, with  bad  memory,  are  also  ominous  signs. 
The  culmination  of  several  prominent  symptoms  will 
admit  of  no  other  explanation,  no  matter  how  much 
the  fact  may  be  denied.  Egotism  of  strength  and 
ability  to  do  unusual  things  is  also  significant. 
■  One  who  claims  that  there  is  no. danger  from  the 
use  of  morphin  and  that  it  can  be  given  him  without 
risk  very  often  betrays  his.  real  condition.  One  who 
is  hypersensitive,  with  the  fear  that  he  will  be  ac- 
cused of  this  addiction,  is  also  an  object  of  suspicion. 

It  may  be  stated  that  neurotics  and  psychopaths 
who  suddenly  develop  great  control  of  their  nervous 
system,  with  serenity  of  manner,  are  under  the  influ- 
ence of  some  chemical  restraint.  One  who  has  been 
previously  a  sufferer  from  nervous  exhaustion  and 
neuralgia,  who  recovers  rapidly  without  any  entail- 
ment of  the  disease,  is  open  to  suspicion  of  using  this 
or  other  drugs. 

Marvelous  so-called  recoveries  from  chronic  and 
long-continued  diseases  by  the  aid  of  some  unknown 
medicines  undoubtedly  follow  the  use  of  some  form 


138  Morphinism 

of  opium.  The  morphinist  who  fully  recovers  and 
claims  to  be  free  from  all  suffering  is  probably  still 
using  it  in  some  other  form. 

^  The  physician  who  claims  marvelous  results  in 
chronic  cases  marked  by  a  great  deal  of  pain,  and 
whose  patients  are  loud  in  praise  of  their  cure,  is  no 
doubt  employing  this  drug. 

It  may  be  stated  thus  in  a  general  way:  The 
sudden,  unexpected  cessation  of  symptoms  that  are 
painful  and  distressing  is  very  often  due  to  narcotics. 
The  alcoholist  who  recovers  rapidly  and  boasts  of  his 
freedom  from  all  possible  relapse  is  frequently  a  mor- 
phinist. Thus,  taking  all  the  symptoms  and  condi- 
tions, the  probability  of  an  accurate  diagnosis,  not- 
withstanding the  denial  of  the  patients,  is  great. 

The  prognosis  in  morphinism  will  vary  very  widely 
according  to  the  condition  of  the  patient,  the  length 
of  the  time  of  the  addiction,  and  the  influence  of 
heredity. 

When  organic  lesions  followed  by  severe  pain  have 
preceded  the  use  of  morphin,  the  future  is  uncertain. 
The  removal  of  the  drug  may  be  followed  by  the 
breaking  out  of  the  original  disease.  If  the  patient 
has  had  prolonged  malaria  and  the  poison  effects  on 
the  blood  and  nervous  system  have  produced  serious 
changes,  the  same  uncertainty  will  follow. 

Where  morphin  has  been  used  ignorantly,  or  from 
a  physician's  prescription  for  the  relief  of  some  tem- 


Diagnosis;  Prognosis;  Complications     139 

porary  pain,  the  permanent  cure  of  the  case  may 
generally  be  expected  to  follow  its  withdrawal. 
Where  its  early  use  began  from  defects  of  environ- 
ment, overwork,  and  general  malnutrition,  equally 
good  results  are  to  be  expected  from  long-continued, 
careful  treatment. 

Where  the  morphinism  has  been  inherited,  or  the 
conditions  which  led  to  it  and  the  length  of  the  ad- 
diction have  extended  over  several  years,  the  prog- 
nosis is  not  hopeful;  although  some  of  the  cases 
recover,  and  remain  free  from  the  drug  for  the  rest  of 
life,  the  majority  relapse  at  uncertain  intervals. 

When  it  can  be  shown  that  physical  injuries,  in- 
cluding shocks,  have  been  the  probable  causes  of  a 
long  addiction,  much  uncertainty  exists  as  to  the 
future  of  the  case.  There  will  be  periods  of  health 
after  the  morphin  has  been  abandoned,  and  some- 
times the  appearance  of  other  defects  which  have 
not  been  recognized  before. 

In  cases  where  the  patient  has  had  a  long,  pre- 
liminary, occasional  use  of  the  drug,  and  then  a 
period  of  protracted  use  until  immunity  to  very  large 
doses  has  been  established,  the  withdrawal  is  always 
difficult  and  the  permanency  of  any  cure  is  somewhat 
doubtful. 

When  morphinism  is  complicated  with  spirit-tak- 
ing and  the  addiction  is  of  short  duration,  the  pros- 
pect of  a  final  cure  is  very  good ;  but  when  the  person 


140  Morphinism 

has  been  alternating  between  spirits,  opium,  mor- 
phin,  and  other  drugs  for  years,  the  withdrawal  of 
morphin  is  nearly  always  followed  by  the  outbreak 
of  an  addiction  to  some  other  drug. 

Some  of  the  remarkable  cures  that  appear  in  medi- 
cal literature,  when  examined  are  found  to  be  per- 
sons who  have  simply  changed  from  morphin  to 
some  other  drug.  Thus,  in  one  instance  a  heredi- 
tary neurotic  was  cured  of  alcoholic  addiction,  and 
two  years  later  was  treated  for  morphinism,  and 
still  later  suffered  from  the  cocain  addiction ;  then 
he  went  back  to  alcohol,  and  finally  died.  In  two 
instances  this  case  was  reported  as  a  successful 
treatment  for  morphinism  and  cocainism. 

In  persons  who  have  become  profoiuidly  neurotic 
through  environment  and  occupation,  with  defective 
nutrition,  and  who  continue  in  the  same  conditions, 
the  prognosis  is  always  grave,  no  matter  what  the 
treatment  may  be. 

In  some  cases  where  morphin  is  taken  for  certain 
spasmodic  conditions,  examples  of  which  are  hys- 
teria, stages  of  intermittent  fever,  sudden  neuralgic 
and  paroxysmal  pains,  its  removal  is  not  likely  to  be 
permanent  unless  the  conditions  for  which  it  was 
taken  have  changed. 

In  nearly  every  case  of  morphinism  the  with- 
drawal of  the  drug  and  the  temporary  recovery  of  the 
patient  are  almost  certain,  but  the  permanency  of 


Diagnosis;  Prognosis;  Complications     141 

these  cures  depends  very  largely  on  the  removal  of 
the  states  and  conditions  which  provoked  its  first 
use.  The  fact  that  relapse  takes  place  is  rather  an 
incident  which  better  judgment  and  more  vigor  on 
the  part  of  the  patient  would  have  prevented. 

A  certain  number  of  cases  relapse  after  treat- 
ment; become  very  earnest  and  eager  to  abandon 
morphin  again;  and  after  a  few  relapses  succeed. 
Hence  it  is  always  well  to  encourage  the  patient  to 
repeated  efforts,  notwithstanding  failures,  for  the 
final  success  of  some  of  these  so-called  "incurable" 
cases  is  illustrated  in  many  examples  in  all  parts 
of  the  country.  As  a  rule,  such  persons,  when  they 
recover,  avoid  all  reference  to  any  past  history, 
hence  are  difficult  to  trace. 

The  ordinary  cases  which  fail,  and  lose  all  ambition 
to  make  any  efforts  for  themselves,  are  recognized  by 
the  public  as  types  of  all  others.  Hence  the  supposi- 
tion that  these  cases  are  largely  incurable.  A  certain 
number  of  persons  whose  addiction  has  continued 
for  many  years,  and  who  have  passed  middle  life  and 
are  very  much  debilitated  physically  and  mentally, 
offer  a  very  interesting  question  for  the  physician, 
whether  it  would  be  better  to  remove  the  morphin 
and  uncover  other  and  more  disturbed  conditions,  or 
continue  the  drug  and  give  the  patient  comparative 
quiet  for  the  remainder  of  life. 

Complications  are  very  common  in  all  these  cases. 


142  Morphinism 

and  the  prognosis  will  vary  widely,  from  the  influ- 
ence of  intercurrent  diseases  and  states  of  mind  and 
body  which  are  beyond  the  control  of  the  patient. 

Not  infrequently  the  question  comes  up  as  to 
the  advisability  of  treating  elderly  morphinists  and 
opium-users  who  seem  not  to  be  greatly  injured  by 
the  use  of  the  drug.  Often  such  persons  who  have 
been  long  addicted  to  the  drug  become  very  anxious 
to  break  away  from  its  influence.  The  prognosis  is 
usually  unfavorable  and  the  treatment  unsatisfac- 
tory. 

The  prognosis  depends  largely  on  the  mental 
condition  of  the  patient;  also  on  the  elements  of 
faith  and  hope,  together  with  the  objects  and  pur- 
poses in  life. 

Persons  who,  from  repeated  failures  and  disap- 
pointments, have  lost  ambition  to  recover  and  regain 
their  previous  health  are  doubtful  cases.  Those  who 
have  prospects  of  success,  who  have  strong  purposes 
to  live  for,  and  are  imbued  with  the  idea  that  it  is  only 
by  conquering  themselves  that  they  can  attain  any 
degree  of  success,  are  hopeful  cases.  Those  who  are 
despairing  pessimists,  no  matter  what  the  addiction 
may  be,  are,  in  the  language  of  another,  "con- 
stantly digging  their  own  graves  and  submitting  to 
burial." 

The  two  extremes  of  melancholia  and  egotistical 
exaltation  are  physical  conditions  to  be  recognized  in 


Diagnosis;  Prognosis;  Complications     143 

the  prognosis.  The  former  is  much  more  grave, 
because  the  efforts  made  by  the  physician  for  re- 
covery are  not  shared  by  the  patient.  In  the 
other  the  confident  expectation  of  the  patient,  if 
rightly  directed,  is  a  very  powerful  aid. 

Where  the  disappointments  and  failures  are  tran- 
sient and  leave  a  faint  impression  on  the  patient's 
mind,  results  are  much  better.  Persons  who  have 
had  previous  treatments  at  home  or  in  asylums,  and 
have  failed,  have  the  element  of  anticipation  and 
repetition  of  the  past  experience  to  overcome ;  hence 
they  are  not  very  hopeful  cases. 

The  detection  of  morphinism  is  often  a  matter  of 
great  importance,  especially  when  the  patient  denies 
the  use  of  the  drug.  The  physiologic  test  of  forced 
abstinence  for  forty-eight  hours  may  not  reveal  the 
actual  condition  because  of  the  clandestine  conceal- 
ment of  morphin  or  the  use  of  some  other  drug  which 
will  check  the  withdrawal  symptoms.  Often  the 
diagnosis  cannot  be  made  with  accuracy,  no  matter 
how  thoroughly  the  surroundings  are  controlled. 

Dr.  Lett,*  of  Guelph,  Ontario,  has  found  the  de- 
tection of  morphin  in  the  urine  to  be  simple  and 
accurate.  He  collects  from  ten  to  twenty  ounces 
of  urine  in  a  suspected  case,  and  if  it  has  not  an 
acid  reaction,  makes  it  acid  with  dilute  hydrochloric 
acid.     Then  he  concentrates  the  urine  to  three  or 

*  "  Morphine  Addiction,"  "Journal  of  Inebriety,"  Oct.,  1898. 


144  Morphinism 

four  ounces,  putting  it  in  a  cool  place  for  twelve 
hours.  After  filtering  it,  carbonate  of  soda  is  added 
to  render  it  alkaline,  after  which  it  is  allowed  to 
stand  for  twelve  hours.  Then  he  filters  and  collects 
the  precipitate  and  washes  it  with  distilled  water 
made  alkaline  by  carbonate  of  soda,  digests  the  dried 
precipitate  with  pure  alcohol  at  a  gentle  heat,  and 
filters.  The  filtrate  is  evaporated  to  dryness.  The 
residue  is  dissolved  with  dilute  sulphuric  acid,  then 
tested  for  morphin  by  iodic  acid.  If  morphin  was 
present,  a  violet  tinge  was  noted.  By  this  method 
he  has  succeeded  in  obtaining  morphin  sulphate  from 
the  urine  of  persons  taking  very  minute  amounts  of  the 
drug,  and  been  able  to  identify  the  crystals  by  means 
of  the  microscope. 

In  all  cases  of  suspected  poisoning  by  opium  or  its 
alkaloids,  frequent  washing  of  the  stomach  is  essen- 
tial. Where  persons  are  discovered  in  a  comatose 
condition,  a  free  washing  may  remove  a  large  quan- 
tity of  morphin,  which  would  otherwise  be  absorbed 
later  and  cause  death.  Washing  many  hours  after 
the  case  was  discovered  has  resulted  in  finding  traces 
of  morphin  and  opium  which  were  not  absorbed. 
The  results  of  each  washing  should  be  preserved  and 
tested.  The  urine  should  also  be  removed  and  kept 
for  examination.  Where  the  absorption  of  the  mor- 
phin into  the  system  has  been  going  on,  the  urine  will 
frequently  show  its  presence. 


Diagnosis;  Prognosis;  Complications     145 

In  every  suspected  case  of  medicolegal  importance 
both  the  urine  and  the  contents  of  the  stomach 
should  be  carefully  preserved  in  clean  bottles  or  jars 
and  placed  in  a  cool  temperature,  where  they  can  be 
■examined  later.  Care  should  be  taken  that  a  suffi- 
cient quantity  is  saved  and,  if  possible,  placed  in 
different  jars,  so  that  comparative  tests  may  be 
made. 

A  comatose  state  followed  by  emesis  should  excite 
suspicion  of  morphin-poisoning,  and  the  contents  of 
the  stomach  should  be  carefully  preserved.  Dr. 
Hamburger,*  of  the  Johns  Hopkins  Hospital,  be- 
lieves that  repeated  washing  of  the  stomach  in  mor- 
phin-  or  opium-poisoning  or  in  suspected  cases  is 
a  most  practical  measure. 

In  a  case  of  opium-poisoning  the  stomach  was 
washed  out  repeatedly  at  intervals  of  one  or  two 
hours,  and  in  each  case  the  fluids,  although  colorless, 
gave  a  morphin  reaction,  showing  that  morphin  was 
excreted  into  the  stomach  from  the  viscus.  This 
evidence  seemed  to  prove  that  excreted  morphin  is 
reabsorbed  and  has  continuous  toxic  properties.  It 
also  explains  cases  of  apparent  recovery  from  the 
toxic  action  of  morphin  followed  by  sudden  relapses. 
It  is  generally  admitted  that  in  large  doses  of  mor- 
phin a  small  quantity  only  may  be  eliminated  by  the 
urine,  and  practically  the  largest  amount  is  eliminated 

*  "  Journal  of  Inebriety,"  Jan.,  1895. 


146  Morphinism 

through  the  stomach.  In  the  case  mentioned  above 
the  first  washing  removed  the  unabsorbed  opium; 
the  second  and  third  washings  brought  the  alkaloids, 
which  could  only  have  come  through  excretion  by 
the  gastric  mucous  membrane. 

The  practical  fact  to  be  remembered  is  that  where 
morphin  or  opium  is  found  in  the  stomach  from  the 
first  washing,  this  process  must  be  repeated  at  short 
intervals  to  remove  the  alkaloids  which  are  excreted 
by  the  mucous  membrane  whether  the  opium  has 
been  taken  by  the  mouth  or  hypodermically.  If  the 
contents  of  the  stomach  in  a  suspected  case  give  the 
meconic  acid  reaction  when  filtered, — namely,  the 
red  color  with  ferric  chlorid  or  ferrous  sulphate, — 
and  if  the  color  persists  on  the  addition  of  hydro- 
chloric acid  and  boiling,  opium  is  present.  If  the 
filtered  fluid  is  made  alkaline  with  sodium  hydrate, 
shaken  up  with  ether,  and  evaporated,  and  the 
yellowish-white  residue  dissolved  in  acidulated 
water,  it  responds  to  the  following  reagents:  pla- 
tinic  chlorid,  iodin  in  potassium  iodid  solution, 
sodium  molybdate,  sulphuric  acid  (Frohde),  potas- 
sium-bismuth iodid,  and  potassium  mercuric  iodid 
— showing  the  presence  of  meconic  acid  and  the 
alkaloids. 

In  the  test  for  morphin  in  the  urine  there  is  much 
difficulty  in  separating  the  morphin  from  the  urea, 
as  they  both  behave  toward  solvents  in  the  same 


Diagnosis;  Prognosis;  Complications     147 

way.  The  control  tests  show  that  urea  does  not  in- 
terfere with  the  following  morphin  reactions.  A 
minute  quantity  of  the  residue  dissolved  in  water 
and  treated  on  a  porcelain  dish  with  a  drop  of  am- 
monium molybdate  gave  a  yellow  precipitate,  and 
the  addition  of  a  drop  or  two  of  concentrated  sul- 
phuric acid  causes  violet,  blue,  and  green,  which 
all  solutions  of  morphin  give  under  the  same  condi- 
tions. 

These  tests  may  furnish  fairly  conclusive  evidence 
of  the  presence  of  opium ;  still,  in  a  question  where 
the  matter  is  life  or  death  they  would  be  insufficient 
of  themselves  to  procure  a  conviction.  To  be  abso- 
lutely certain  of  the  presence  of  opium  in  a  mixture 
the  meconic  acid  and  morphin  must  be  isolated  and 
purified,  and  then  only  can  the  results  obtained 
furnish  conclusive  evidence.  Color  tests  are  insuffi- 
cient and  rarely  positive. 

It  is  fortunate  that  any  continuous  use  of  morphin, 
even  for  a  brief  time,  is  usually  marked  by  changes 
and  symptoms  which  are  usually  not  traceable  to 
other  causes.  These  symptoms,  when  carefully 
studied,  bring  confirmatory  proof,  which,  together 
with  the  chemical  tests,  establish  conviction  beyond 
all  reasonable  doubt. 

Many  cases  of  morphinism  are  concealed  during 
the  lifetime,  and  only  after  death  is  the  addiction 
discovered.     The  following  are  examples : 


148  Morphinism 

A  widow  aged  forty-five,  of  wealth,  and  pre- 
viously healthy,  suddenly  became  an  invalid,  suffer- 
ing from  many  complex  and  obscure  symptoms 
which  indicated  serious  organic  disease.  Several 
eminent  physicians  were  consulted,  both  in  this 
country  and  in  Europe,  and  widely  differing  plans 
of  treatment  were  followed  without  success.  She 
manifested  alarm  and  extreme  anxiety  to  recover, 
and  seemed  to  be  thoroughly  honest  in  following  out 
all  the  directions  given.  Finally  she  died  from 
pneumonia.  After  death  her  body  was  found  cov- 
ered with  marks  of  the  needle,  and  the  evidence  of 
her  morphin  addiction  was  apparent.  She  had  con- 
cealed this  in  the  most  adroit  way  for  years,  and 
when  questioned  stoutly  denied  using  any  such  drug. 

Another  example  is  that  of  a  robust  clergyman 
who,  at  fifty  years  of  age,  suddenly  became  erratic  in 
conduct,  and  showed  great  emotional  changes.  He 
would  sit  up  at  night  and  sleep  during  the  day.  Was 
alternately  depressed  and  exalted.  At  times  his 
pulpit  exercises  were  of  a  delirious  and  melancholic 
character.  At  others  they  were  childish  and  stupid. 
These  conditions  were  diagnosed  as  due  to  changes  of 
the  brain  and  nervous  system  from  organic  disease. 
He  was  examined  and  treated  by  many  eminent  au- 
thorities without  success.  Finally  he  was  taken  to 
the  hospital  suffering  from  a  fractured  femur,  and 
soon   afterward  became   delirious   and   died.     His 


Diagnosis;  Prognosis;  Complications     149 

morphin  addiction  was  discovered  after  his  death. 
For  years  he  had  carefully  concealed  it,  so  that  it 
was  not  suspected  by  his  intimate  friends. 

A  third  example,  which  excited  a  great  deal  of 
comment  at  the  time,  was  that  of  a  noted  politician, 
who  suddenly  displayed  great  changes  of  character 
and  judgment,  and  for  years  conducted  himself 
in  the  most  unusual  manner,  disappearing  suddenly 
when  most  wanted,  acting  wildly,  to  the  detriment 
of  his  interests,  showing  great  suspicion  of  his 
friends  and  personal  dishonesty.  He  was  treated 
for  obscure  brain  disease,  spending  months  at 
watering-places  and  sanatoriums,  and  finally  died 
suddenly.  From  scars  on  his  body,  and  the  needles 
found  in  his  possession,  the  morphin  addiction  was 
discovered. 

Such  cases  as  these  are  by  no  means  infrequent. 
Their  detection  during  life  will  depend  on  a  careful 
study  of  the  symptoms  and  progress  of  the  case. 
They  show  that  it  is  possible  to  use  morphin  secretly 
for  some  time,  and  the  symptoms  which  follow  will 
not  be  rightly  interpreted  unless  the  patient  is 
under  observation  for  a  long  time. 


CHAPTER  VI 

TREATMENT;    ASYLUM    CONDITIONS;    DRUGS; 
HYGIENIC  MEASURES 

Control  of  Patient.  Removal  from  Home.  Private  Asylums. 
Seeking  New  Remedies  and  New  Methods  of  Treatment.  Exalta- 
tion and  Delusion.  Restraint  and  Freedom.  Different  Methods 
of  Withdrawal.  How  They  Are  to  be  Applied.  Some  Rem^edies  to 
be  Used.  The  Needle  and  the  Use  of  Opium  as  a  Remedy.  Nar- 
cotics in  the  Treatment.  Insomnia;  Its  Treatment.  Water  and 
Its  Application.  Different  Plans  of  Treatment.  The  Author's 
Plan;  Its  Details.  After  the  Treatment,  Psychic  Element  to  be 
Noted.  Placebos.  Time  of  Treatm.ent.  Delusive  Symptoms. 
Theories  of  the  Withdrawal  Symptoms.  Treatment  at  Home. 
Cannot  do  Business  During  the  Treatment.     Examples. 

The  first  thing  in  the  treatment  must  be  to  secure 
the  control  of  the  patient.  His  own  voHtion  must 
be  subservient  to  that  of  the  physician.  He  cannot 
reason  or  direct  as  to  the  plan  of  treatment.  Failure 
always  follows  self-treatment. 

Removal  from  home  is  most  essential  to  secure 
this  control.  As  in  other  neuroses,  particularly  in- 
sanity, hysteria,  and  forms  of  neurasthenia,  only 
control  by  and  contact  with  strangers  are  effectual. 
This  helps  to  break  up  the  morbid  trend  of  reasoning 
and  associations,  which  cannot  be  done  at  home  and 
with  relatives. 

Private  and  special  asylums,  if  properly  managed, 

150 


Treatment ;  Asylum  Conditions  ;  Etc.     151 

have  superior  advantages  which  cannot  be  obtained 
elsewhere.  In  such  places  the  stimulating  firmness 
of  a  stranger,  if  coming  with  tact,  does  much  to 
rouse  up  a  weakened  will.  The  surroundings,  with 
the  central  purpose  of  removing  the  morphin,  will 
encourage  personal  effort  on  the  part  of  the  patient. 
This  idea  should  be  made  dominant  at  the  beginning. 

The  tendency  of  each  person  is  to  exaggerate  the 
importance  of  conditions  and  surroundings  in  the 
treatment ;  also  to  consider  the  process  of  withdrawal 
and  final  cure  dependent  on  some  insignificant  cir- 
cumstances or  conditions.  This  idea  is  to  be  antagon- 
ized and  overcome  by  the  efforts  of  the  physician  and 
attendant.  If  the  patient's  mind  can  be  concen- 
trated and  have  full  faith  in  the  means  used,  this 
is  additional  help.  This  often  follows  after  a  few 
days'  treatment  in  most  cases,  and  is  the  basis  of 
final  ciire. 

If  the  mind  is  unsteady  and  unable  to  retain  con- 
fidence in  the  measures  used,  the  physician  must  be 
resourceful  enough  to  supply  this  deficiency  and 
retain  the  confidence  of  the  patient.  In  some  cases 
the  morphinists  are  continuously  casting  about  for 
some  new  means  and  measures  superior  to  those  used. 
No  plan  of  treatment,  however  enthusiastically  be- 
gun,  is  ever  voluntarily  continued  long.  The  mind 
seems  to  be  continuously  occupied  in  finding  new 
and  better  methods. 


152*  Morphinism 

If  the  patient  is  a  physician,  the  difficulty  is  in- 
creased, and  the  result  of  the  treatment  is  more  un- 
certain. If  he  can  be  persuaded  to  trust  implicitly 
to  the  physician  and  attendant,  having  no  concern 
as  to  the  means  and  methods  of  treatment,  the  re- 
covery is  far  more  certain.  The  persons  who  are 
unable  to  repose  confidence  in  any  means  or  measures 
for  their  treatment,  except  for  a  brief  time,  and  who 
are  suspicious,  egotistic,  and  determined  to  trust 
their  own  judgment,  and  insist  upon  deciding  ques- 
tions of  treatment,  are  very  largely  of  the  incurable 
class. 

This  delusional  state  is  insanity,  and  not  infre- 
quently the  first  stage  of  general  paresis.  Such  cases 
dread  control  and  are  averse  to  following  the  uniform 
line  of  conduct  planned  by  the  physician.  They  in- 
sist on  freedom  to  come  and  go,  and  demand  implicit 
trust  in  their  promises  to  carry  out  the  treatment. 
Such  cases  need,  first  of  all,  sharp  restraint,  with  full 
control  of  the  surroundings,  and  absolute  conformity 
to  all  rules  and  regulations.  Without  this,  success- 
ful treatment  is  always  difficult.  To  those  who  have 
confidence  in  the  means  employed  and  show  a  dis- 
position to  trust  implicitly  to  the  physician  and 
attendant,  restraint  of  this  kind  is  not  necessary. 
When  they  seem  willing  to  bear  pain  and  discom- 
fort, and  to  make  an  effort  to  help  themselves, 
recovery  is  rapid. 


Treatment;  Asylum  Conditions  ;  Etc.     153 

The  question  of  restraint  is  dependent  largely  on 
the  condition  of  the  individual.  In  some  instances  it 
is  stimulating  and  helpful;  in  others,  irritating  and 
depressing.  In  most  cases  a  measure  of  espionage  and 
control  is  absolutely  necessary.  This  cannot  be  de- 
termined clearly  at  the  beginning  of  the  treatment, 
but  will  be  ascertained  from  personal  observation 
and  study  of  the  case. 

In  some  instances  the  surroundings  of  an  institu- 
tion and  the  fact  of  being  in  an  asylum  are  a  re- 
straining power  fully  recognized;  in  others,  the 
opposite  condition  obtains.  To  many,  the  person- 
ality and  control  of  the  physician  or  attendant  are 
sufficiently  stimulating,  and  persons  are  able  to  re- 
cover without  further  restraint. 

Surveillance  should  be  continued  for  a  long  time 
after  the  cessation  of  active  treatment,  and  the  pa- 
tient's condition  and  surroundings  should  be  a  special 
subject  of  inquiry  for  the  purpose  of  avoiding  temp- 
tation* and  causes  which  favor  relapse.  Thus,  the 
business  or  professional  man  should  not  go  back  at 
once  to  his  old  life  and  subject  himself  to  all  the 
strains  and  drains  which  brought  on  his  former 
addictions.  Nor  should  the  person  of  wealth  return 
to  habits  of  indolence  and  excess.  The  effort  of  the 
physician  should  be  to  impress  on  the  patient's  mind 
the  need  of  a  radical  change  in  his  life  and  methods 
of  living.     This  shotild  be  done  at  the  beginning  of 


154  Morphinism 

the  treatment.  The  profound  neurasthenia  associ- 
ated with  mental  enfeeblement  and  moral  palsies 
are  conditions  present  in  all  cases.  These  facts 
should  be  considered  in  the  treatment. 

The  withdrawal  of  the  drug  removes  an  active 
cause,  and  is  only  preliminary  in  the  treatment.  In 
many  cases  it  simply  unmasks  states  not  sus- 
pected before,  but  in  all  instances  it  enables  the 
physician  to  lay  down  some  plan  of  treatment  for 
the  future  restoration  of  the  victim. 

In  the  removal  of  the  morphin  three  methods  have 

'warm  advocates:  First,  the  immediate  and  entire 

withdrawal;  second,  the  rapid  reduction,  extending 

over  two  or  three  days ;  third,  the  gradual  reduction, 

lasting  two  or  three  weeks. 

-  The  first  method,  of  immediate  withdrawal,  has 
many  advocates  abroad.  Levinstein  practised  this 
method  with  success,  and  urged  it  as  the  most 
rational  method  of  radical  cure.  The  cases  were 
shut  up  in  asylums  and  the  morphin  withdrawn  at 
once.  Bromids,  hot  baths,  and  hot  soups  were  given 
freely.  After  the  third  day  the  withdrawal  symp- 
toms subsided,  and  in  a  week  the  patient  was  quiet 
and  comfortable.  This  method  has  been  opposed 
and  pronounced  inhuman.  Practically  it  is  used  in 
station-houses  and  jails,  where  persons  who  are  mor- 
phinists arrested  for  crime  are  forced  to  abandon 
the   drug.     Periods   of  withdrawal   symptoms   are 


Treatment;  Asylum  Conditions  ;  Etc.     155 

often  not  recognized  as  such,  but  are  ascribed  to 
some  other  condition.  For  this  reason  many  per- 
sons are  treated  for  some  other  condition,  and  when 
confined  in  jails  have  periods  of  acute  illness,  from 
which  they  recover. 

It  is  exceedingly  doubtful  if  the  collapse  from  sud- 
den withdrawal  ever  ends  in  death,  although  the 
effect  upon-  the  patient's  mind  and  body  is  often 
very  severe.  In  large  cities  physicians  to  the 
station-houses  find  laudanum  and  morphin  most 
excellent  stimulants,  particularly  in  the  sudden 
collapses  which  indicate  the  strong  probability  of 
morphinism. 

In  private  practice  this  method  is  impracticable, 
although  it  has  been  tried  with  the  consent  of  the 
patient.  It  requires  proper  surroundings  and  ex- 
cellent attendants  as  well  as  close  medical  watching. 

The  rapid  reduction  covering  two  or  three  days  or 
a  longer  period  is  very  feasible  and  successful  in 
many  cases.  It  requires  special  surroundings,  with 
trained  help,  and  careful  medication.  The  usual 
method  is  to  reduce  the  quantity  of  morphin  taken, 
no  matter  how  large,  to  two  or  three  grains  daily. 
This  can  be  done  without  much  suffering,  showing 
that  the  enormous  doses  used  have  not  had  their 
proportional  effects.  No  doubt  a  large  quantity 
of  the  morphin  is  unabsorbed,  and  remains  in  the 
system,  with  the  possibility  of  suddenly  develop- 


156  Morphinism 

ing  profound  narcotism  and  death.  Thus,  a  per- 
son using  twenty  grains  daily  will  die  suddenly  from 
no  observable  causes.  Morphin  in  this  quantity 
has  been  taken  for  a  long  time  without  unusual 
symptoms  or  premonitions  of  death.  Unexpectedly 
its  cumulative  action  concentrates  on  the  nerve- 
centers,  and  death  follows.  This  possibility  is  always 
present,  even  when  small  doses  are  used,  and  in  most 
cases  death  is  attributed  to  other  causes.  The  mor- 
phin can  be  removed  easily  if  the  doses  are  divided 
and  given  at  short  intervals  down  to  a  small 
amount.  Thus,  a  patient  taking  fifteen  or  twenty 
grains  a  day  may  not  notice  the  withdrawal  down  to 
five  or  six  grains. 

It  is  essential  in  this  rapid  reduction  to  clear  out 
the  alimentary  canal  with  salines  or  copious  drafts 
of  hot  water.  Sometimes  a  calomel  cathartic  is  very . 
good.  Soda  preparations  are  very  useful,  even  when 
relaxation  of  the  bowels  takes  place.  An  interval 
of  twenty-four  or  forty-eight  hours  should  elapse 
after  the  first  withdrawal  before  another  reduction 
is  made.  The  amount  should  be  determined  by  the 
condition  of  the  patient.  Usually  one  or  two  grains 
can  be  withheld,  and  if  the  remainder  is  given  at 
night,  the  withdrawal  symptoms  are  less  severe. 
Placebos  may  be  given  if  the  mind  is  morbidly  sen- 
sitive, but  they  should  be  nothing  more  than  bitter 
tonics. 


Treatment;  Asylum  Conditions ;  Etc.     157 

In  this  rapid  withdrawal  stage  it  should  be  the 
study  of  the  physician  not  to  use  other  narcotics  as 
substitutes  too  early  in  the  treatment.  If  while 
giving  four  grains  of  morphin  a  day  cannabis  indica 
or  any  of  the  bromids  is  given,  the  effects  will  be 
uncertain,  both  of  the  morphin  and  of  the  substitute. 
The  fact  should  be  remembered  that  in  opium  addic- 
tions narcotics  neutralize  each  other's  effects  rather 
than  intensify  them.  Thus,  morphin  and  hyoscya- 
mus  given  together  are  antagonistic.  Either  of  these 
drugs  alone  would  have  a  more  decisive  action  than 
when  combined. 

The  bromids  also  work  in  the  same  way.  Larger 
doses  are  required  to  produce  bromism  when  mor- 
phin is  used  at  the  same  time,  and  its  ctunulative 
action  is  more  severe  and  long  continued.  The 
same  is  noticeable  in  other  drugs.  Practically  it  is 
found  better  to  abandon  the  morphin  before  the 
substitutes  in  later  treatment  are  used. 

Narcotics  may  be  given  in  the  morning  when  the 
morphin  has  been  taken  the  night  before,  and  it  is 
customary  in  this  rapid  withdrawal  to  give  the  mor- 
phin at  night,  and  to  use  the  substitute  during  the 
day.  Tinctures  should  be  used  with  care  at  this 
time  because  of  the  danger  of  alcoholic  addiction. 
Certain  persons  are  very  susceptible  to  the  para- 
lyzing action  of  alcohol  at  this  period. 

Some  of  the  remarkable  cases  reported  of  the  pain- 


158  Morphinism 

less  withdrawal  of  morphin  have  been  effected  by 
simply  substituting  some  alcoholic  tinctures  for  the 
morphin.  In  the  same  manner  the  withdrawal  of  the 
morphin  and  the  substitution  of  codein  and  other  al- 
kaloids, or  laudanum  or  other  preparations  of  opium, 
is  simply  changing  from  one  addiction  to  another. 

Many  of  the  specific  preparations  contain  some 
form  of  opium,  the  substitution  of  which  for  morphin 
is  simply  a  change  in  the  form,  of  the  drug.  To 
abandon  morphin  and  to  depend  upon  alcohol  in  its 
various  forms  is  not  curative  in  any  sense.  The  rule 
should  be  that  no  alcohol  be  used  in  the  with- 
drawal stage. 

The  acuteness  of  the  insomnia,  depression,  and 
neuralgia  which  follow  the  rapid  removal  of  morphin 
should  be  treated  by  baths,  hot  and  cold  water  appli- 
cations, also  massage.  When  the  morphin  is  en- 
tirely withdrawn,  many  drugs  may  be  used  to  lessen 
the  acuteness  of  the  symptoms,  prominent  among 
which  are  valerian,  asafetida,  hyoscyamin,  cannabis 
indica,  and  the  coal-tar  derivatives.  As  a  rule,  they 
should  be  given  in  large  doses,  frequently  repeated, 
xmtil  several  doses  are  taken ;  then  abandoned.  No 
one  drug  should  be  given  more  than  two  or  three  days 
at  a  time,  unless  its  effects  are  so  marked  as  to  de- 
mand its  continuance. 

The  vegetable  narcotics  seem  to  be  valuable  in 
many  cases,  but  do  not  all  act  alike.     In  some  cases 


Treatment;  Asylum  Conditions ;  Etc.     159 

they  are  very  powerful;  in  others,  they  are  of  no 
value.  The  phosphate  of  soda  is  a  valuable  remedy, 
and  can  be  used  continuously  during  this  period. 

The  rapid  withdrawal  stage  should  not  last  more 
than  six  or  ten  days.  In  some  instances  a  much 
shorter  time  is  practicable.  The  reduction  of  the 
morphin  to  four  or  five  grains  the  first  day,  and  the 
third  day  afterward  its  still  further  reduction  to  three 
grains  taken  at  night,  will  be  found  practicable. 
Then,  if  possible,  substitute  deodorized  tincture  of 
opium,  in  proportionate  quantities,  the  fourth  night. 
The  sixth  night  morphin  can  be  reduced  still 
further,  and  then  abandoned  on  the  eighth  or 
ninth  day.  After  this  time  narcotics  which  have 
been  found  effective  are  to  be  given  at  night.  These 
can  be  dropped  after  one  or  two  weeks  without 
special  suffering.  Strychnin,  quinin,  and  other  ac- 
tive tonics  are  very  valuable  at  this  period.  Farad- 
ism,  massage,  and  confinement  in  bed  all  are  very 
valuable  means. 

This  method  of  rapid  withdrawal  will  tax  the 
therapeutic  resources  and  skill  of  the  physician  to 
the  utmost.  Each  case  will  vary  widely  in  both 
physical  and  psychic  symptoms.  In  one  instance 
applications  of  water  in  the  form  of  baths,  hot  appli- 
cations, or  spongings  of  the  body  will  be  effective. 
In  another,  feeding,  confinement  in  bed,  and  per- 
sonal attention  by  attendants  are  sufficient.     In  a 


i6o  Morphinism 

third  case,  exercise,  mental  diversions,  and  frequent 
change  will  lessen  the  intensity  of  the  symptoms. 
In  others,  drug  restraint  and  narcotism  are  demanded 
imperatively.  The  same  diversity  of  symptoms  will 
appear  after  the  morphin  is  withdrawn,  and  the  same 
skill  to  adapt  the  special  means  to  the  end  will  be 
required. 

In  the  third  method  of  treatment,  the  gradual 
reduction  extending  over  a  period  of  several  weeks, 
much  the  same  course  will  be  pursued,  only  less 
rapidly.  The  morphin  should  be  reduced  to  four  or 
five  grains  the  first  few  days  of  treatment.  Then  a 
slow  withdrawal  daily  or  weekly  should  follow. 

Where  the  needle  has  been  used,  the  difficulties 
will  be  increased  because  of  the  fascination  which 
follows  from  the  effects  of  drugs  taken  in  this  way. 
The  rule  is  that  the  needle  should  be  abandoned  as 
soon  as  possible  and  the  drug  be  taken  by  the  mouth. 

I  have  found  solid  opium  to  be  better  borne  by  the 
stomach  than  morphin.  This,  with  the  deodorized 
tinctiire,  can  be  given  in  decreasing  doses  with  good 
effect.  This  form  of  opium  can  be  given  concealed 
in  bitter  tonics,  and,  where  the  stomach  will  tolerate 
it,  is  valuable  as  a  substitute,  and  can  be  reduced  in 
strength  without  being  recognized  by  the  patient. 
In  many  cases  it  is  practicable  to  abandon  the  mor- 
phin for  this  form  of  drug  as  soon  as  possible,  and 
then  to  slowly  or  rapidly  take  this  away.     Opium 


Treatment;  Asylum  Conditions  ;  Etc.     i6i 

in  the  gum  or  powder  is  often  efficacious  as  a 
substitute  for  morphin.  The  narcotism  from  opium 
in  gum  or  powder  is  more  prolonged  and  agreeable 
by  the  absence  of  stimulation,  and  the  withdrawal 
symptoms  have  less  of  the  mental  and  hysteric  ele- 
ment. It  is  found  to  be  less  difficult  to  withdraw 
opium  in  the  powder  than  morphin,  and  that  in 
many  cases  the  bad  symptoms  are  less  prominent  in 
the  withdrawal  period. 

Where  the  reduction  is  likely  to  extend  over 
several  weeks,  owing  to  the  hypersensitiveness  of  the 
patient  and  his  disinclination  to  bear  pain  and  dis- 
comfort, great  attention  should  be  given  to  the  diet 
and  regular  habits  of  living,  and  also  avoidance  of  all 
extremes  of  exercise,  nervous  excitement,  overeating, 
and  excesses  of  every  kind. 

It  is  important  to  increase  the  vigor  and  strength 
of  the  patient  in  every  possible  way.  It  is  found 
that  with  increasing  vigor  the  neuralgias  disappear. 
Often  iron  and  phosphorus  tonics  are  very  valuable 
for  this  purpose.  The  salines  in  some  form  are 
indispensable.  The  flushing  of  the  alimentary  canal 
by  cathartics  is  equally  important.  Narcotics,  as 
before  remarked,  are  of  little  value,  except  in  the 
very  last  stages,  when  the  morphin  is  finally  with- 
drawn. 

A  gradual  system  of  developing  the  vigor  and 
healthy  functional  activity  of  the  body  ^,nd  at  the 


i62  Morphinism 

same  time  slowly  removing  the  morphin  is  the  plan 
to  be  pursued.  In  some  instances  the  morphin  is 
reduced  by  infinitesimal  fractions  of  a  grain  daily, 
on  the  supposition  that  nature  will  accommo- 
date itself  to  this  slow  withdrawal.  Others  sub- 
stitute some  mild  narcotic  early  in  the  withdrawal 
process.  This,  in  the  author's  experience,  has  been 
very  unsatisfactory.  The  exact  plan  and  method  of 
withdrawal  must  vary  with  the  patient  and  the 
physician. 

Sometimes  the  surroundings  have  much  influence. 
If  in  an  institution  where  these  can  be  controlled, 
the  conditions  for  withdrawal  may  be  carried  out 
with  mathematic  exactness.  The  preferable  plan  is 
to  drop  the  morphin  in  half-grains  at  intervals 
of  ten  days  or  two  weeks,  and  to  accustom  the 
system  to  adapt  itself  to  the  reduced  doses  by 
continuing  daily  a  fixed  amount.  In  one  case  a 
grain  was  taken  away  every  week  until  only  a 
half-grain  was  used  daily.  The  intervals  after 
the  first  few  days  were  passed  without  much  suf- 
fering. At  the  last  the  half-grain  was  removed 
and  bromids  substituted  for  it.  The  second  day 
hyoscyamin  and  trional  were  used  with  good  effect. 
In  a  week  or  so  the  patient  was  able  to  do  without 
any  narcotic. 

After  the  morphin  is  withdrawn  the  severity  of  the 
irritation  j,nd  deliriiun  is  sometimes  best  relieved 


Treatment;  Asylum  Conditions  ;  Etc.     163 

after  the  second  day  by  return  to  the  drug  again  in 
some  concealed  form  for  one  or  two  doses.  An  ex- 
ample of  this  was  that  of  a  morphinist  who  after 
the  final  withdrawal  was  intensely  melancholic  and 
delusional.  This  condition  increased  until  on  the 
evening  of  the  second  day  a  dose  of  morphin  con- 
cealed was  given.  The  relief  and  sleep  which  fol- 
lowed lasted  twenty-four  hours,  after  which  substi- 
tutes were  able  to  produce  a  degree  of  comfort,  and 
the  restoration  was  rapid  and  uneventful. 

This  course  is  not  always  followed  by  the  same  re- 
sults. The  patient  will  demand  the  same  drug,  not 
knowing  what  it  is,  and  the  skill  of  the  physician  will 
be  taxed  to  find  a  substitute  which  will  be  satis- 
factory. Manias  following  the  withdrawal  of  mor- 
phin can  be  broken  up  in  this  way,  and  also  phobias, 
but  great  skill  is  necessary  to  prevent  their  recur- 
rence. In  one  case  of  destructive  mania  from  the 
withdrawal  of  morphin  the  drug  was  given,  again 
breaking  up  the  mania;  then  forced  cold  and  hot 
showers  were  substituted,  which  prevented  the  re- 
turn of  the  mental  disturbances,  and  final  recovery 
ensued. 

After  the  crisis  is  past  other  and  milder  substi- 
tutes may  be  given  with  excellent  effects.  If  the 
patient's  mind  retains  consciousness  of  the  condi- 
tions which  have  existed,  this  treatment  is  followed 
by  renewed  confidence  and  faith  in  recovery.     In- 


164  Morphinism 

somnia  should  not  be  treated  by  hypnotics  with 
any  degree  of  regularity.  The  danger  of  another 
addiction  is  so  great  that  it  is  unwise  to  use  any  of 
the  hypnotics  except  for  a  brief  time. 

Tobacco  should  be  stopped  early  in  the  withdrawal 
treatment.  It  always  seriously  complicates  the 
progress  of  the  case.  After  the  withdrawal  symp- 
toms are  passed  its  resumption  is  very  commonly 
followed  by  relapse.  Beef -tea  and  beef-extracts  are 
unsatisfactory,  and  in  most  cases  are  nerve  stimu- 
lants of  decided  inferiority,  and  seriously  complicate 
the  progress  of  the  case.  Fruit- juices  and  grain 
products,  with  milk,  are  the  best  nutrients  which  can 
be  given. 

Often  an  abdominal  bandage,  wet  in  either  cold  or 
hot  water,  has  a  soothing  effect  on  the  sympathetic 
nerves  of  the  abdomen,  checking  diarrhea  and  gastric 
trouble.  Cold  water  applications  to  the  spine  in  the 
form  of  ice-bags  are  very  serviceable. 

The  methods  of  treatment  which  have  become 
popular  both  in  this  country  and  abroad  are  one  of 
slow,  gradual  withdrawal  of  the  drug;  the  other, 
that  of  rapid  abandonment  within  four  or  six 
days.  The  former  plan  is  used  in  all  the  large 
hospitals,  and  has  many  warm  advocates.  The 
latter  is  often  used  in  asylums  where  hydropathic 
measures  can  be  applied. 

If   it   is   determined   to   withdraw   the   morphin 


Treatment;  Asylum  Conditions  ;  Etc.     165 

rapidly,  great  stress  is  laid  upon  the  use  of  cathartics 
at  the  start  to  wash  out  the  digestive  canal,  and  the 
use  during  the  entire  treatment  of  preparations  of 
soda  to  prevent  or  neutralize  the  acidity  of  the 
stomach  and  bowels.  This  latter  is  very  essential 
in  all  methods  of  treatment.  Indications  of  either 
are  met  by  phosphate  of  soda  for  the  former  and 
bicarbonate  of  soda  for  the  latter,  in  five-  or  ten- 
grain  doses  two  or  three  times  a  day. 

A  plan  of  treatment  by  the  substitution  of  bromid 
of  sodium  deserves  notice.  After  the  amount  of 
morphin  taken  has  been  ascertained  and  the  ali- 
mentary canal  has  been  washed  out,  the  quantity 
is  reduced  one-half,  and  bromid  of  sodium  substi- 
tuted, beginning  with  fifty  grains  three  times  the 
first  day,  the  second  day  increasing  each  dose  10 
grains,  and  continuing  this  until  the  maximum  dose 
is  100  grains  given  three  times  in  twenty-four  hours. 
The  drug  is  then  discontinued.  The  sedative  effect 
that  follows  its  use  may  last  for  two  or  three  weeks, 
and  finally  passes  away.  The  morphin  is  rapidly 
reduced,  and  on  the  third  day  is  abandoned.  The 
reflex  irritation  is  overcome,  and  the  patient  is  un- 
conscious of  any  pain  or  suffering,  lying  in  a 
quiescent,  stuporous  condition. 

Having  secured  the  sedative  effect,  the  next 
object  is  to  eliminate  the  bromid.  This  is  accom- 
plished by  hot  baths  twice  a  day,  and  the  use  of  spirits 


1 66  Morphinism 

of  nitrous  ether,  acetate  of  potash,  or  infusion  of 
digitalis.  As  the  bromism  passes  off,  some  restless- 
ness may  follow,  which  is  easily  controlled  by  warm 
baths  or  any  mild  narcotic. 

The  sleeplessness  which  is  very  common  from  the 
withdrawal  is  peculiar  after  the  use  of  bromid  in 
coming  on  after  midnight.  The  early  part  of  the 
evening  and  the  afternoon  the  patient  is  excessively 
sleepy,  but  after  midnight  the  insomnia  appears. 
This  is  treated  with  sulphonal  and  other  hypnotics. 
The  diarrhea  is  not  prominent,  and  never  lasts  longer 
than  one  or  two  days,  and  does  not  require  any 
astringent.  The  debility  which  follows  from  the 
bromid  relaxation  and  the  morphin  withdrawal  is 
treated  with  strychnin,  one-twentieth  of  a  grain 
three  times  daily.  Strychnin  should  not  be  given 
during  the  bromid  administration,  as  the  two  drugs 
are  antagonistic. 

Serious  objections  have  been  made  to  this  treat- 
ment, and  while  its  value  is  apparent,  in  certain 
cases  it  has  not  been  considered  a  safe  and  practi- 
cable remedy.  Bromidization  of  a  sensitive  brain 
is  sometimes  more  serious  in  its  effects  than  mor- 
phin itself.  The  effects  of  bromid  sedation  have 
been  traced  months  afterward  in  low  vitality, 
stupor,  and  general  debility. 

Dr.  Levinstein's  plan,*  by  the  sudden  withdrawal 

*  "  Morbid  Cravings  for  Morphia,"  Smith,  Elder  &  Co.  1898 


Treatment;  Asylum  Conditions;  Etc.     167 

of  morphin  and  the  substitution  of  cold  douches, 
alcoholic  drinks,  chloral,  and  bromids,  is  open  to 
similar  objections,  and  may  be  injurious  in  its  after- 
effects on  the.  patient  in  some  instances. 

Dr.  Kellogg  *  has  recommended  a  modified  plan,  in 
which  morphin  is  withdrawn  in  two  or  three  days 
and  cold  and  hot  packs  substituted,  with  massage, 
acid  drinks,  and  liquid  foods.  Douches  and  appli- 
cations of  heat  to  different  parts  of  the  body  are 
given  to  control  the  withdrawal  symptoms.  This 
method  requires  special  surroundings,  and  in  large 
institutions  is  very  valuable. 

Another  method,  urged  by  a  physician  who  claims 
to  have  large  experience,  is  the  diminution  of  the 
morphin  one-eighth  of  a  grain  a  day,  and  substitu-' 
tion  of  strychnin,  cannabis  indica,  and  chloral.  This 
has  not  proved  satisfactory,  and  is  not  applicable  to 
every  case.  Large  doses  of  quinin  have  also  been 
given  to  alleviate  the  withdrawal  symptoms,  and 
occasionally  its  results  are  so  pleasing  that  many 
persons  suppose  this  to  be  a  remedy  approaching  a 
specific. 

To  find  a  substitute  or  a  drug  which  will  com- 
pletely and  safely  relieve  the  discomfort,  uneasiness, 
and  pain  following  the  withdrawal  of  morphin  is  the 
dream  of  the  credulous  physician,  and  the  boast  of 
the  charlatan  and  quack,  but  so  far  it  is  unrealized. 

♦  "  Journal  of  Inebriety." 


1 68  Morphinism 

The  difficulty  is  that  no  two  cases  are  alike,  and 
while  the  effects  of  morphin  are  practically  the 
same,  the  injury  which  follows  from  other  anes- 
thetic drugs  varies  widely  in  each  case.  In  one  case 
the  bad  effects  of  the  drug  used  to  lessen  the  irrita- 
tion and  reflex  disturbances  will  not  be  apparent  for 
some  time,  then  it  appears  in  some  chronic  state. 
In  another  case  the  damage  from  morphin  will  be 
noted  in  the  higher  brain-centers,  and  the  effects  of 
the  drug  used  in  the  withdrawal  will  seem  to  inten- 
sify the  condition.  Bromidization  in  morphin  cases 
often  produces  disturbances  of  the  motor  and 
sensory  centers,  and  these  continue  for  a  length 
of  time.  In  all  probability  some  peculiar  suscepti- 
bility exists  favoring,  motor  palsies,  and  bromidiza- 
tion fixes  this  state,  and  the  patient  has  never  the 
same  use  of  the  extremities  afterward.  A  drug  that 
would  produce  stupor  and  lessen  the  reflex  irritation 
in  one  case  would  be  a  positive  injury  in  another. 
In  another  case  all  attempts  to  control  the  with- 
drawal symptoms  by  a  drug  that  will  be  effectual 
will  be  practically  injurious  and  provoke  dangerous 
symptoms. 

A  method  of  treatment  by  elimination,  used  by 
many  persons,  is  very  practical  in  many  cases.  This 
treatment  is  based  on  the  theory  that  the  continued 
use  of  morphin  produces  marked  changes  in  the 
glandular  secretions.     When  morphin  is  withdrawn. 


Treatment;  Asylum  Conditions;  Etc.     169 

there  is  resumption  of  these  glandular  functions, 
which  follow  in  a  irregular  manner.  First,  perspira- 
tion and  sneezing,  accompanied  with  yawning ;  then 
diarrhea,  at  first  half  bilious,  half  fecal,  and  then 
watery;  later,  vomiting,  in  which  bile  and  gastric 
juice  appear;  spermatorrhea,  salivation,  and  mus- 
cular cramps  follow  each  other. 

Each  glandular  apparatus  attempts  to  resume  its 
normal  function,  and  succeeds  or  fails  in  proportion 
to  the  degree  with  which  these  organs  have  been 
impregnated  with  morphin.  The  mechanism  ap- 
pears to  be  that  of  an  effort  to  throw  off  the  morphin 
in  the  epithelial  and  endothelial  desquamation  of 
the  impregnated  mucous  membrane.  Assuming 
this  theory  to  be  correct,  the  stronger  the  reaction  of 
the  organism,  the  more  abundant  will  be  the  desqua- 
mation and  the  more  rapidly  will  organic  regenera- 
tion be  brought  about.  The  convalescence  will  be 
shorter,  the  system  be  more  thoroughly  renewed,  and 
the  chances  of  a  relapse  lessened. 

The  obvious  indication  from  this  theory  will  be  the 
rapid  elimination  of  the  altered  glandular  elements, 
provoking  the  appearance  of  each  secretion  and  ex- 
citing glandular  activity  by  every  known  method, 
while  lessening  the  quantity  of  morphin  at  the  same 
time.  Hence,  purgatives,  diuretics,  and  diaphore- 
tics should  be  used  concurrently.  Under  the  influ- 
ences of  these  medicines  the  quantity  of  morphin 


170  Morphinism 

may  be  rapidly  diminished,  and  the  resumption  of 
glandular  activity  will  begin  before  the  removal  of 
the  drug  is  complete.  The  results  have  proved  in 
many  cases  that  the  withdrawal  symptoms  were 
less  intense,  the  heart's  action  less  labored,  and 
the  pain  diminished.  In  persons  with  diseased 
hearts  no  signs  of  heart  failure  or  syncope  have  fol- 
lowed this  treatment. 

It  is  urged  that  the  withdrawal  of  morphin  is  quite 
different  from  the  elimination  of  the  drug  from  the 
system.  If  the  latter  is  not  carried  out,  conva- 
lescence from  the  former  is  impossible,  and  fatal 
results  may  follow.  Elimination  is  therefore  con- 
sidered equal  in  importance  to  gradual  withdrawal. 
With  active  elimination  at  the  start,  the  rapid 
and  harmless  withdrawal  is  possible  in  all  cases; 
but  without  this,  the  slow  removal  of  morphin 
leaves  the  patient  exposed  to  accidents  and  serious 
dangers. 

In  this  form  of  treatment  sulphonal,  bromid,  and 
chloral  are  found  to  be  injurious  and  impractica- 
ble. Phosphate  of  codein  has  been  very  warmly 
praised.  Spartein  and  caffein  are  very  effectual 
in  many  cases.  The  method  of  treatment  which 
has  been  found  most  practical  by  the  author  is 
that  of  gradual  reduction,  going  from  stage  to 
stage, — now  slow,  then  rapid, — being  governed 
by  the  condition  of  the  case,  the  history,  and  pres- 


Treatment;  Asylum  Conditions ;  Etc.     171 

ent  conditions.  It  may  be  divided  into  three 
stages : 

First,  the  preparatory  stage,  in  which  an  effort  is 
made  to  ascertain  the  smallest  amount  of  morphin 
which  can  be  taken  without  discomfort  to  the  pa- 
tient. This  sometimes  requires  an  extended  obser- 
vation of  a  week  or  more.  Many  patients  use  far 
more  morphin  than  they  imagine,  being  careless  and 
inaccurate  as  to  time,  and  the  quantity  taken.  Others 
intentionally  deceive  themselves  and  others,  boast- 
ing that  they  only  take  a  certain  amount,  when  in 
reality  this  is  only  the  minimum.  Having  secured  the 
proper  surroundings  and  control  of  the  case,  the 
patient's  statement  of  the  amount  he  is  taking  is 
accepted  and  he  is  given  a  Hke  amount  for  the  pur- 
pose of  testing  his  accuracy.  If  this  is  found  to 
produce  marked  narcosis,  it  is  evident  that  it  is  more 
than  is  essential  for  comfort.  If  he  is  restless  and 
uneasy,  it  is  less  than  his  usual  dose. 

These  conditions  will  vary  largely  the  first  two  or 
three  days.  The  fact  of  coming  under  treatment  in 
strange  surroundings  and  under  new  conditions  pro- 
duces a  psychic  condition  which  will  derange  the  ner- 
vous system,  requiring  more  than  the  accustomed 
dose  of  morphin  at  first.  After  the  patient  has  ac- 
quired a  degree  of  confidence  and  become  famiUar 
with  the  surroundings,  an  approximate  estimate  can 
be  attained.     If  it  is  found  that  he  is  comfortable 


172  Morphinism 

on  eight  or  ten  grains  a  day,  this  is  assumed  to  be 
the  average  quantity  necessary  to  produce  reason- 
able sedation. 

Having  ascertained  the  character  of  the  case,  the 
next  question  is  the  gradual  or  rapid  withdrawal  of 
the  drug.  If  the  addiction  is  an  acquired  one  in  a 
person  previously  well,  and  free  from  neurotic  strain 
and  organic  disease,  and  the  time  of  addiction  is 
limited  to  two  or  three  years  and  associated  with  the 
use  of  spirits,  a  rapid  withdrawal  is  the  most  practi- 
cable. The  conditions  present  are  always  neuras- 
thenia and  anemia  and  various  functional  disturb- 
ances, which  are  made  worse  by  concealment  with 
drugs  and  the  narcotism  of  morphin.  Having  found 
the  amount  of  morphin  the  person  takes  and  corrected 
in  a  measure  the  digestive  disturbances  which  exist, 
the  second  stage  of  treatment  begins.  The  first  step 
will  be  to  abandon  the  morning  dose  of  morphin  and 
to  concentrate  the  amount  given  from  noon  to  six 
in  the  afternoon,  rarely  giving  any  after  six  or  seven 
o'clock  in  the  evening,  the  object  being  to  get  the 
narcotic  effect  during  the  night,  also  to  break  up  the 
plan  of  its  previous  use.  Where  it  had  been  taken  in 
small  doses  at  short  intervals,  larger  doses  are  given 
at  long  intervals.  If  the  absence  of  morphin  in  the 
early  morning  causes  suffering,  baths  are  given, 
stimulating  foods,  and  hot  milk  or  acid  drinks  if  the 
stomach  will  bear  them.     If  the  discomfort  is  severe, 


Treatment;  Asylum  Conditions ;  Etc.     173 

opium  pills  of  half  a  grain  or  one  grain  may  be 
given  for  a  few  days,  but  not  continued  long  enough 
to  establish  a  desire  for  it. 

When  the  system  is  accustomed  to  this  change,  the 
morphin  may  be  reduced  one-half  the  usual  dose  at 
once.  If  ten  grains  are  taken  daily,  five  grains  will 
suffice.  If  given  by  the  needle,  the  diminished 
amount  is  seldom  recognized ;  if  by  the  stomach,  the 
partial  withdrawal  is  more  apparent. 

Later,  according  to  the  condition  of  the  patient, 
a  still  further  diminution  is  made,  and  if  the  suffering 
is  marked,  a  preparation  of  cinchona  bark,  usually 
an  infusion  in  half -ounce  doses,  combined  with  ten 
drops  of  deodorized  opium,  is  given.  Most  cases 
bear  reduction  without  any  particular  discomfort 
down  to  one  or  two  grains.  Then  increasing  doses 
of  opium  with  cinchona  become  a  good  substitute, 
and  the  morphin  can  be  withdrawn  at  once. 

If  the  needle  addiction  is  present,  the  use  of  the 
needle  must  be  kept  up  with  regularity,  occasionally 
substituting  one  or  two  grains  of  dionin  in  place  of 
the  morphin. 

When  opium  is  not  borne  well  by  the  stomach,  pills 
of  lupulin,  black  haw,  valerian,  cannabis  indica,  and 
hyoscyamus  may  be  alternated  until  one  is  found 
having  narcotic  properties  sufficient  to.  lessen  the 
extreme  irritation.  Baths  are  to  be  given  every 
day  during  the  reduction  period,  and  phosphate  of 


174  Morphinism 

soda  in  small  doses  should  be  used  two  or  three 
times  a  day. 

In  from  ten  to  fifteen  days  the  morphin  can  be  en- 
tirely abandoned;  then  comes  the  third  stage  of 
treatment  for  the  withdrawal  symptoms.  The  ef- 
fort here  will  be  to  diminish  their  intensity,  particu- 
larly that  of  insomnia  and  restlessness. 

Prolonged  hot  baths,  either  in  a  tub  or  from  a 
shower  or  by  packs,  are  very  useful,  and  very 
satisfactory  in  many  cases.  Nitrate  of  strychnin  is 
in  some  cases  of  great  service,  particularly  where  the 
needle  has  been  used.  Beginning  at  one-thirtieth  of  a 
grain,  the  amount  may  be  increased  up  to  one-tenth 
of  a  grain  given  three  or  four  times  a  day.  If  it  pro- 
duces excitement,  both  muscular  and  mental,  it 
should  be  discontinued.  Phosphoric  acid  with  nux 
vomica  are  remedies  whose  effects  are  very  pro- 
nounced. Extract  of  bull  nettle,  given  in  fifteen- 
or  twenty-drop  doses,  has  been  found  very  effica- 
cious in  removing  the  restlessness  and  encouraging 
sleep  during  this  stage. 

Care  must  be  taken  of  the  diet.  Small  quanti- 
ties of  food  should  be  given  at  short  intervals  rather 
than  full  meals  at  stated  hours:  If  the  bowels  be- 
come troublesome  through  dysenteric  discharges,  in- 
creased doses  of  cinchona  with  capsicum  will  be  useful.  • 
Tea  and  coffee  during  this  period  have  been  in  some 
instances  medicinal  in  calming  the  restlessness  and 


Treatment;  Asylum  Conditions  ;  Etc.     175 

allaying  the  discomforts.  In  others,  they  are  both 
stimulating  and  irritating.  Cocoa  seems  preferable, 
and  should  be  used  often,  when  found  agreeable. 

Electricity  has  been  found  valuable  in  some  cases ; 
in  others,  an  irritant.  The  static  current  seems 
best  adapted,  and  is  often  followed  by  decided  rest 
and  relief  from  discomfort.  Electric  baths  are  very 
highly  praised  by  some  authorities,  but  it  is  proba- 
ble that  their  value  depends  upon  the  peculiarities  of 
the  person.  Experience  differs  as  to  its  practical 
use  as  a  general  remedy. 

The  withdrawal  period  may  last  from  four  to  ten 
days,  sometimes  longer.  When  it  has  passed  away, 
the  patient  recovers  in  a  large  measure  and  only 
suffers  from  general  weakness  and  depression  of 
spirits.  Care  should  be  taken  at  this  time  not  to  use 
any  drugs  that  are  known  to  the  patient,  particu- 
larly those  that  are  likely  to  produce  pleasing  effects 
and  be  taken  afterward  for  their  quieting  effects. 

The  muscular  delirium,  or  intense  desire  to  use  the 
muscles  of  the  legs  in  walking,  is  overcome  by  mas- 
sage and  vibratory  machines  that  shake  and  exercise 
the  muscles.  A  few  minutes  of  this  seems  to  ex- 
pend the  muscular  energy  and  to  take  away  this 
uneasy  feeling. 

The  peculiar  delirium  cannot  be  overcome  by  ex- 
ercise in  the  open  air  without  danger  of  reaction.  In 
one  case  walks  of  two  or  three  miles  a  day  for  a 


176  Morphinism 

time  resulted  in  extreme  prostration  and  relapse. 
In  another  case  excessive  exercise  in  a  gymnasium 
was  followed  by  the  same  result.  Limited  indul- 
gence of  this  desire  is  helpful,  with  massage  and  hot 
and  cold  baths  daily. 

Warm  baths  at  night,  if  not  too  stimulating,  fol- 
lowed by  rubbing,  seem  to  be  more  sedative  than  in 
the  early  stages  of  treatment.  Mild  exercise  in  the 
open  air  is  often  of  great  value,  the  difficulty  being 
that  the  person  is  liable  to  overexert  himself  and 
suffer  from  muscular  fatigue.  Short  rides  and 
walks  are  of  more  advantage,  the  intervals  being 
passed  in  a  reclining  position  on  a  couch. 

In  most  cases,  to  remove  the  clothes  in  the  middle 
of  the  day,  darken  the  windows,  and  go  to  bed  with 
all  the  conditions  favorable  for  sleep,  is  a  most  ex- 
cellent measure.  After  a  short  time  lengthening 
periods  of  sleep  will  follow. 

During  the  withdrawal  period  the  patient  should 
see  very  little  company,  do  no  business,  and  have  no 
strain  on  the  mind  if  it  can  possibly  be  avoided.  In 
some  cases,  particularly  in  those  who  are  overfed 
and  inclined  to  corpulency,  a  Turkish  bath  with  mild 
rubbing  every  day,  either  in  the  forenoon  or  early 
in  the  evening,  will  be  found  very  advantageous.  In 
a  thin,  spare  person,  with  acute  sensitiveness  and 
hyperesthesia  of  the  skin,  showers  and  hand  massage 
are  of  great  value.     In  the  absence  of  these  meas- 


Treatment;  Asylum  Conditions  ;  Etc.     177 

ures,  sponging  with  warm  salt  water,  or  with  water 
containing  four  ounces  of  vinegar  to  the  gallon,  is 
very  soothing.  For  the  various  anesthetic  and 
hyperesthetic  conditions,  also  for  the  local  neu- 
ralgias, hot  and  cold  applications  are  very  useful. 

After  opium  or  morphin  has  been  discontinued 
and  the  withdrawal  symptoms  have  partially  passed 
away,  some  conception  of  the  changes  taking  place 
in  the  system,  due  in  whole  or  in  part  to  morphin, 
will  be  apparent.  Also  how  far  the  fimctional  de- 
pressions and  conditions  associated  with  morphin 
will  demand  its  use  again. 

If  the  morphinism  began  with  neuralgic  states  or 
rheumatism,  neurasthenia  or  insomnia,  we  shall  have 
a  condition  of  disturbance  of  the  nervous  system 
which  may  very  likely  come  again  into  prominence 
from  the  slightest  exciting  cause.  These  conditions 
must  be  anticipated,  and  early  states  of  exhaustion 
expected  to  recur  unless  prevented  and  antagonized 
by  surroundings  of  life  and  methods  of  living. 

Much  of  the  after-treatment  must  depend  on  the 
condition  of  the  patient,  and  should  be  directed  to 
create  better  nerve  and  cell  nutrition.  This  is  very 
often  accomplished  by  massage,  graduated  exercises, 
and  the  use  of  such  tonics  as  phosphorus,  arsenic, 
quinin,  iron,  or  strychnin. 

Where  the  stomach  is  impaired  and  foods  are  not 
readily   assimilated,    oil    inunctions    are    valuable. 


1 78  Morphinism 

• 

Care  should  be  taken  not  to  produce  too  sharp  an 
appetite  in  the  early  stages  of  convalescence,  be- 
cause of  the  difficulty  of  assimilating  the  food. 
Reconstruction -goes  on  slowly  and  cannot  be  hur- 
ried by  stomach  tonics.  Foods  should  be  given 
at  short  intervals,  and  in  small  quantities,  followed 
by  periods  of  rest. 

Several  quite  eminent  authorities  have  urged  that 
morphinomaniacs  should  be  treated  hydropathically 
after  the  first  four  or  five  weeks  from  the  withdrawal 
of  the  drug.  This  treatment  should  consist  of  warm 
showers  several  times  a  day,  gradually  increasing  in 
coldness  up  to  ice-cold  water.  The  claim  is  that  the 
shock  to  the  cutaneous  nerves  acts  as  a  tonic,  quick- 
ening the  vital  forces  and  increasing  the  activities  of 
the  circulation  as  well  as  elimination.  It  is  clear 
that  in  many  instances  this  treatment  has  produced 
excellent  results. 

A  prominent  case  went  the  rounds  of  the  medical 
press  a  few  years  ago,  in  which  the  principle  of  the 
methods  of  treatment  was  cold  showers.  The  pa- 
tient was  given  from  two  to  four  showers  a  day  with 
brisk  rubbing.  The  morphin  was  removed  in  the 
first  week  and  no  treatment  was  given  except  that  of 
cold  water  and  rubbing.  The  recovery  was  rapid 
and  without  any  untoward  symptoms.  The  usual  de- 
pression and  withdrawal  symptoms  were  absent.  It 
was  evident  that  this  was  not  a  typical  case,  although 


Treatment;  Asylum  Conditions  ;  Etc.     179 

it  showed  clearly  the  possibilities  of  treatment  by 
hydropathic  measures. 

This  represents  in  outline  some  general  facts  con- 
cerning the  withdrawal  of  morphin  and  the  general 
after-treatment  of  a  large  number  of  cases. 

Another  class  of  morphinists,  where  a  long,  gradual 
removal  of  the  morphin  is  deemed  most  advisable, 
are  those  of  the  neurotic  type.  This  distinction  is 
very  practical  in  many  cases,  particularly  in  the  lines 
of  treatment,  which  will  vary  materially,  with 
reference  to  the  early  and  later  neurotic  states  and 
conditions  of  the  patient.  The  method  of  removal 
of  the  drug,  and  the  after-treatment,  also  the  general 
principles  to  be  observed,  and  the  conditions  and 
symptoms  present,  require  more  specialized  study 
and  care. 

Persons  of  this  class  are  those  in  which  there  is  a 
strong  predisposition  to  exhaustion  from  overwork, 
and  who  are  often  unequal  to  the  wear  and  tear  of 
life,  and  have  used  morphin  for  relief  of  the 
fatigue  symptoms;  also  those  in  whom  morphin 
was  used  to  cover  up  some  organic  change  and  lesion 
attended  with  severe  pain,  and  others  in  whom  the 
morphinism  grew  out  of  physical  injuries  and  ex- 
haustive diseases  of  the  general  nervous  system. 
Such  persons  should  be  treated  on  the  gradual  with- 
drawal plan. 

The  first  preliminary  period  should  begin,  as  be- 


l8o  Morphinism 

fore  stated,  with  an  exhaustive  study  of  the  condi- 
tions which  have  been  influential  in  the  origin  and 
growth  of  the  use  of  morphin.  To  this  must  be 
added  a  very  clear  clinical  study  of  how  far  morphin 
has  damaged  or  perverted  the  functional  or  organic 
activities  of  the  body,  and  the  present  state  of  the 
organism.  This  period  should  be  carefully  consid- 
ered. The  amount  of  morphin  taken  and  its  pecu- 
liar action,  how  far  it  has  deranged  the  nutrition  and 
disturbed  the  normal  activities  of  the  body,  and  the 
exact  amount  used,  both  as  to  time  and  quantity,  all 
demand  attention. 

Having  controlled  the  surroundings  and  secured 
the  confidence  of  the  patient,  the  withdrawal  should 
be  from  an  eighth  of  a  grain  to  a  quarter  of  a  grain  a 
day,  changing  the  time  of  taking  it,  and  using  no 
substitute  drugs  until  the  amount  taken  is  reduced 
to  three  grains  or  less  a  day.  In  the  mean  time  soda 
preparations  and  mineral  cathartics  may  be  given 
regularly,  with  acid  tonics,  effervescing  mineral 
salts,  and  daily  baths. 

The  withdrawal  of  the  morphin  down  to  three 
grains  or  less  should  be  done  in  the  first  ten  days ; 
then,  after  the  system  gets  accustomed  to  this 
amount,  a  reduction  of  a  quarter  or  half  a  grain 
should  be  made  at  intervals  of  a  week,  and  the  dose 
continued  until  the  system  becomes  accustomed  to 
it  without  particular  suffering. 


Treatment;  Asylum  Conditions ;  Etc.     i8i 

The  uneasiness  and  discomfort  which  may  appear 
from  the  withdrawal  are  to  be  overcome  by  baths, 
diversion,  limited  outdoor  exercise,  and  massage.  If 
there  is  anemia,  some  preparation  of  iron  may  be 
given  for  a  few  days  at  a  time,  then  abandoned.  All 
sedatives  are  to  be  given  in  the  afternoon  and  early 
evening.  Attention  should  be  given  to  the  bowels, 
to  prevent  accumulation  of  any  morbid  matter,  and 
to  keep  them  active  every  day. 

Sometimes  faradism  is  of  great  service  in  these 
cases.  The  current  is  applied  over  the  spine  and  the 
back  of  the  neck  down,  once  or  twice  a  day  a  few 
moments  at  a  time.  Some  writers  believe  that 
applications  of  water,  either  hot  or  cold,  are  more 
efficacious  for  these  conditions. 

When  the  amount  of  the  drug  has  been  reduced 
below  two  grains,  it  is  possible  to  use  tonics,  beginning 
with  the  mild  preparations  of  cinchona  and  gentian, 
being  always  careful  to  prevent  them  from  stimulat- 
ing the  stomach  and  creating  abnormal  himger, 
always  reducing  the  drug  and  increasing  and  chang- 
ing the  tonic  cautiously. 

Care  should  be  taken  not  to  use  spirits,  and  to 
avoid  all  preparations  of  opium  except  in  a  con- 
cealed form  and  in  single  doses  for  a  specific  pur- 
pose. At  a  favorable  time  when  the  patient  is  in 
the  best  psychic  and  hygienic  condition,  the  drug 
can  be  taken  away  at  once  and  deodorized  tincture 


i82  Morphinism 

of  opium  substituted  in  decreasing  doses,  combined 
with  bitter  tonics  to  conceal  its  taste. 

Later,  this  can  be  substituted  by  bull  nettle,  pasa- 
dena  inflorata,  or  any  of  the  preparations  of  hops, 
valerian,  or  narcotics  of  this  class.  Cannabis  indica 
can  often  be  used  with  very  good  effect,  especially 
for  the  temporary  removal  of  the  worst  symptoms. 

No  effort  should  be  made  to  keep  the  patient  con- 
tinuously narcotized,  but  rather  to  withdraw  all 
narcotics  and  sedatives,  substituting  tonics  and 
hygienic  measures  such  as  baths,  massage,  and  diver- 
sion. The  hysteric  element  so  often  developing  in 
these  cases  requires  mental  treatment  as  often  as 
physical. 

After  the  morphin  is  withdrawn  the  same  general 
treatment  should  be  pursued,  varying  only  from  the 
particular  conditions  and  circumstances  of  the  case. 
If  on  the  removal  of  the  morphin  some  old  neuralgic 
condition  reappears,  it  must  be  met  with  tonics  and 
mild  sedatives.  The  time  for  the  gradual  with- 
drawal may  extend  over  two  or  more  months  accord- 
ing to  the  circumstances  and  conditions. 

The  effort  of  many  physicians  to  treat  all  persons 
alike  by  the  same  medicines  or  needle  injections  is 
empirical.  The  recovery  of  some  cases  treated  in 
this  manner  is  due  largely  to  unknown  causes.  In 
all  cases  there  is  a  psychic  element  which  should 
be  recognized  and  treated. 


Treatment;  Asylum  Conditions ;  Etc.     183 

The  impressions  are  vivid,  and  exert  a  very  posi- 
tive influence,  whether  they  come  from  a  needle  or 
the  application  of  unknown  drugs  administered  in  a 
mysterious  way,  or  are  due  to  some  motive  of  alarm 
or  desire  which  has  been  presented  to  the  mind. 

The  after-treatment  should  combine  nerve  and 
mental  rest,  with  tonic  diversions,  of  which  travel, 
change  of  cUmate,  and  hydropathic  measures  are 
essential.  In  one  case  a  lawyer,  after  recovery, 
spent  four  years  in  the  country  before  he  resumed 
his  profession.  A  physician  went  to  mining  in  the 
West,  and  returned  two  years  later  fully  restored. 
In  many  instances  a  radical  change  of  occupation 
and  living  is  almost  specific  for  final  cure. 

Dr.  Berillon,*  of  Paris,  has  had  much  success  in 
the  psycho-therapeutic  treatment  of  morphinism. 
He  recognizes  a  distinction  between  morphinism 
and  morphinomania.  In  one,  morphin  is  occasion- 
ally used  to  relieve  some  feeling  of  discomfort,  misery, 
and  pain;  in  the  other  a  dominant  impulse  per- 
vades the  entire  system  for  relief  from  pain  and 
misery. 

He  believes  that  in  the  first  classification  there  are 
temporary  conditions  of  anesthesia  or  hyperesthesia 
which  may  be  overcome  by  a  mental  impression; 
also  that  the  will  can  be  aroused  to  control  fully  the 
depression  and  pain  impulses.     In  the  other  case  the 

*  "  Annals  of  Psychological  Medicine."     1898. 


184  Morphinism 

mind  is  a  prey  to  an  exaggerated,  hyperesthetic 
fear  of  suffering.  Under  these  circumstances  all 
thought  and  action  are  concentrated  to  avoid  the 
pain  and  prevent  it. 

The  morphinist  has  the  delusion  that  he  is  able  to 
control  his  condition  and  can  stop  the  use  of  the 
drug  at  any  time.  The  idea  of  free-will  is  always 
present,  but  the  inabiHty  to  exercise  it  is  never 
explainable  in  any  way.  While  the  morphino- 
maniac  rarely  speaks  of  his  ability  to  stop,  or  boasts 
of  his  power  to  do  so  until  he  has  secured  relief  from 
pain  by  the  drug.  Then  all  feelings  of  alarm  and 
excitement  pass  away  the  moment  it  is  secured. 

The  morphinist  is  usually  irresolute,  changeable ; 
his  nutrition,  his  intellectual  faculties,  and  his  pur- 
poses in  life  are  doubtful  and  uncertain.  Sugges- 
tion may  be  tried,  and  the  idea  of  certain  health 
may  become  fixed  in  his  mind.  The  essential 
part  of  the  treatment  is  to  exalt  the  desire  to 
be  free  from  the  drug,  and  to  make  the  thought 
of  its  use  odious,  and  so  rouse  all  ambition 
and  purpose  to  discontinue  it.  The  suggestive 
treatment  is  pressed  on  the  mind  of  the  patient 
at  frequent  intervals,  while  the  morphin  is  re- 
duced rapidly  and  by  concealed  methods.  A 
process  of  demorphinization  takes  place  in  which 
reliance  on  the  drug  is  diminished  and  dependence 
on  the  suggestion  is  increased  with  each  effort. 


Treatment;  Asylum  Conditions ;  Etc.     185 

A  number  of  cases  are  cited  in  which  this  method 
of  treatment  was  successful,  and  the  conclusion 
reached  that  the  cures  by  this  means  were  more  per- 
manent than  those  of  any  other.  The  period  of 
convalescence  was  shorter  and  the  malaise  which 
followed  was  less  prominent  and  troublesome.  Still, 
it  is  evident  that  this  method  of  treatment  is  limited 
to  recent  cases  and  requires  peculiar,  persistent  treat- 
ment on  the  part  of  the  operator  as  well  as  a  very 
sensitive  subject  to  deal  with. 

It  is  common  in  the  practical  treatment  of  these 
cases  to  substitute  placebos  and  get  the  same  re- 
sults, showing  that  certain  cases  may  be  perma- 
nently impressed  by  suggestion;  organic  changes 
may  follow  employment  of  this  aid,  but  as  a  specific 
it  cannot  be  depended  upon. 

The  morphinomaniacs  are  moral  paralytics,  hence 
are  not  easily  controlled  by  suggestion  for  any  length 
of  time.  The  treatment  by  suggestion  is  very  valua- 
ble, but  it  requires  frequent  repetition  and  continu- 
ous reiteration  to  produce  any  effect.  Often  the 
effect  of  the  needle  with  water  only  is  more  powerful 
than  suggestion.  There  seems  to  be  attached  to  this 
method  of  medication  mental  certainty  which  no 
other  means  can  excel.  The  use  of  the  needle  with 
simple  hot  water  injections  continued  for  a  long  time 
has  proved  very  valuable. 

The  ordinary  cases  of  morphin  require  at  least 


1 86  Morphinism 

six  to  ten  months'  treatment.  Any  less  time  is 
seldom  followed  by  permanent  results.  The  first 
two  months  are  occupied  in  the  removal  of  the  mor- 
phin  and  with  the  reduction  of  the  acute  symptoms. 
The  patient  then  begins  to  feel  returning  strength, 
and  assumes  that  he  is  cured  beyond  danger  of  re- 
lapse. At  the  end  of  the  third  month  restlessness 
and  irritability  appear,  which  he  attributes  to  the 
surroundings,  and  perhaps  to  the  want  of  confidence 
in  him  manifested  by  his  physician  and  friends.  He 
believes  the  remedy  is  freedom  from  all  restraint 
and  resumption  of  his  former  occupation  and  sur- 
roundings. He  will  resort  to  coffee,  tea,  and,  per- 
haps, stronger  stimulants,  to  overcome  this  restless- 
ness. When  under  treatment,  bromids  or  some  of 
the  milder  narcotics,  with  frequent  baths,  will  be 
found  necessary.  The  restlessness  will  pass  off, 
and  return  again  in  a  few  weeks,  taking  on  perhaps 
a  different  form. 

Sometimes  bronchitis  will  appear,  with  insomnia, 
and  distressing  melancholia,  and  other  neurotic 
conditions,  all  of  which  disappear  suddenly,  showing 
their  neurotic  origin.  These  nerve  storms  are 
periods  of  danger  in  which  the  patient  is  liable  to 
relapse.  The  treatment  should  extend  over  many 
months  so  as  to  cover  these  attacks.  If  the  case  can 
be  conducted  safely  over  these  storm  periods,  the 
prognosis  is  hopeful.     To  discharge  a  patient  after 


Treatment;  Asylum  Conditions  ;  Etc.     187 

withdrawal  of  the  drug  is  simply  a  waste  of  time  and 
effort.  If  he  continues  well,  it  will  be  an  accident, 
an  exception  to  the  rule.  Where  the  symptoms  are 
complex,  a  year  is  the  shortest  time,  under  the  most 
favorable  circumstances,  for  permanent  cure. 

To  withdraw  the  morphin  in  ordinary  cases  is  the 
least  difficult  measure  in  treatment.  While  the 
symptoms  of  withdrawal  may  be  unpleasant  and 
startling,  they  are  self-limited,  and  yield  readily  to 
proper  treatment. 

A  few  weeks  after  the  withdrawal  of  the  morphin 
the  appetite  is  excessive.  At  the  end  of  the  second 
month  the  patient  presents  every  indication  of 
restoration,  with  unusual  confidence  in  his  strength 
and  vigor,  and  believes  that  he  will  never  relapse. 
If  he  has  been  under  the  care  of  a  nurse  up  to  this 
time,  he  resents  any  further  assistance  and  aid 
in  this  direction,  and  believes  that  he  has  moral 
as  well  as  physical  strength  to  take  perfect  care  of 
himself.  Whether  he  stays  imder  supervision  or  has 
full  liberty  to  come  and  go,  or  wherever  he  goes,  the 
result  is  almost  certain  relapse. 

The  last  few  months  may  be  spent  away  from  an 
asylum  under  the  care  of  a  physician,  but  it  should 
never  be  forgotten  that  the  removal  of  the  morphin, 
if  followed  by  relapses,  always  produces  discourage- 
ment and  diminished  vigor  of  will-power  with  in- 
creased hopelessness    of  cure.      When   there   is  a 


1 88  Morphinism 

hereditary  tendency,  all  the  conditions  of  exaltation 
and  depression  should  be  combated  by  continuous 
care  and  medical  treatment.  When  the  disease  has 
affected  the  brain  to  the  extent  of  producing  organic 
weakness,  the  time  of  treatment  should  be  greatly 
lengthened,  and  the  protection  of  the  patient  against 
temptation  and  conditions  of  mental  and  physical 
debility  is  absolutely  necessary. 

The  central  fact  to  be  remembered  is  that  the 
withdrawal  of  morphin  is  not  the  cure,  but  only  the 
beginning,  A  long  period  of  building-up  and  re- 
storative treatment  must  follow  before  the  brain  and 
nervous  system  can  attain  the  degree  of  vigor  essen- 
tial to  control  the  neurotic  symptoms  which  follow. 

Not  infrequently  periodicity  of  insomnia,  with  ex- 
treme restlessness,  appears  after  the  withdrawal  of 
morphin.  Such  attacks  grow  less  and  less  with  the 
increasing  vigor  of  the  person ;  although  in  some  in- 
stances they  continue  for  a  lifetime,  yet  they  will  be- 
come more  and  more  under  the  control  of  the  will. 

Of  the  various  theories  to  account  for  the  with- 
drawal symptoms  in  morphinists,  Dr.  Waugh,*  of 
Chicago,  suggests  the  following  explanation :  "  When 
any  toxic  agent  is  taken  into  the  system,  there  is 
developed  in  the  body  an  antidote  or  a  counter- 
poison.  If  the  dose  of  the  drug  taken  be  increased 
slowly,  the  power  of  the  system  pari  passu  to  elab- 

*  "  Medical  World  and  Alkaloid."     1896-1899. 


Treatment;  Asylum  Conditions  ;  Etc.     189 

orate  a  corresponding  dose  of  the  antidote  increases, 
which  lessens  the  toxic  effect.  If  the  taking  of  the 
poison  becomes  habitual,  the  production  of  the 
counter-poison  becomes  also  habitual.  If,  then,  the 
taking  of  the  drug  be  suddenly  stopped,  the  elabora- 
tion of  the  antidote  does  not  necessarily  cease  at  the 
same  time,  because  its  production  has  become  a  habit. 
Hence,  what  we  term  the '  withdrawal  symptoms'  fol- 
lowing the  disuse  of  the  drug-habit  are  really  symp- 
toms of  poisoning  by  the  systemic  poison,  which  no 
longer  is  needed  to  antidote  the  drug  taken,  and 
exerts  its  toxic  action  on  the  body  producing  it.  If 
this  view  is  correct,  we  will  find  when  the  habitual 
drug  is  withheld  symptoms  due  to  the  leucomain.  A 
study  of  the  disorders  of  the  intestinal  canal  shows 
that  two  toxic  bodies  are  present,  known  as  the 
atropin  alkaloid  and  the  muscarin  alkaloid.  Whether 
it  is  in  the  intestinal  canal  that  the  toxins  in  nar- 
comania are  formed,  I  do  not  know,  but  I  believe  that 
this  is  the  laboratory  where  the  toxic  principles  of 
uremia,  diabetes,  and  many  other  affections  are 
compounded.  It  is  probable  that  the  toxins  in 
morphinism  and  other  drug  states  are  prepared  in 
the  bowels.  This  would  seem  to  be  confirmed  by 
the  results  of  intestinal  canal  antisepsis." 

Assuming  Dr.  Waugh's  theory  to  be  correct,  cer- 
tainly the  most  direct  antidote  to  the  leucomain  will 
be  the  drug  taken  habitually,  and  hence  the  gradual 


1 90  Morphinism 

withdrawal  is  better  than  the  sudden  stoppage ;  but 
our  experience  has  been  that  it  is  still  better  to  sub- 
stitute for  the  drug  some  other  antagonist  of  the 
toxic  leucomain. 

Some  cases  are  given  in  which  the  treatment  was 
based  upon  this  theory,  and  the  result  was  very  satis- 
factory. The  principal  fact  of  treatment  was  sharp 
elimination  by  calomel  and  magnesia  and  antiseptic 
drinks  containing  eucalyptol  and  zinc  sulphocar- 
bolate.  All  experience  sustains  the  assertion  of  the 
necessity  for  keeping  the  alimentary  canal  in  a  septic 
condition  during  the  withdrawal  period  and  for  a 
long  time  after.  In  connection  with  this,  elimina- 
tion through  the  skin  and  urinary  organs  is  also 
essential. 

The  question  is  often  asked,  Is  it  possible  to  treat 
morphinism  at  home?  This,  of  course,  will  depend 
upon  a  great  variety  of  circumstances.  A  promi- 
nent man  of  wealth  insisted  on  home  treatment,  and 
his  physician,  having  some  knowledge  of  such  cases, 
consented  on  the  condition  that  he  would  confine 
himself  to  a  single  room  for  a  stated  time  and  under 
no  circumstances  leave  it.  He  was  placed  in  charge 
of  an  attendant  night  and  day,  who  kept  strict  sur- 
veillance over  him,  not  allowing  him  to  go  out  or  to 
hold  any  communication  with  any  but  the  members 
of  his  family.  His  clothes  were  taken  away  from 
him  by  stealth  and  found  to  contain  morphin  in  the 


Treatment;  Asylum  Conditions;  Etc.     191 

hems  and  lining.  This  he  had  secreted,  thinking 
the  doctor  would  deprive  him  of  the  drug  and  thus 
increase  his  suffering.  Massage  and  hot  sponging 
were  given  daily.  The  morphin  was  removed,  the 
withdrawal  symptoms  were  slight,  and  the  patient 
made  a  good  recovery.  Notwithstanding  his  desire 
to  abandon  the  drug,  he  tried  various  means  of 
securing  it  surreptitiously  by  bribing  his  attendant. 
The  difficulty  in  such  cases  would  be  apparent  to 
any  one. 

In  another  case  a  lady  consented  to  go  into  con- 
finement in  her  own  room  tmder  the  care  of  a  special 
nurse.  After  a  few  weeks'  treatment  it  was  found 
that  she  was  procuring  morphin  secretly.  An 
examination  disclosed  the  fact  that  during  the  night 
she  suspended  a  cord  from  her  window  to  the  ground, 
and  the  gardener  attached  to  the  end  of  it  a  small 
package  of  morphin,  which  she  drew  up  and  con- 
cealed, using  it  in  small  quantities  unobserved  even 
by  a  careful  trained  nurse. 

These  cases  are  probably  not  common,  but  they 
indicate  the  difficulties  in  conducting  successful 
treatment  in  the  home  surroundings  and  ordinary 
conditions  of  life. 

Specific  drugs  for  home  treatment  are  always 
fraudulent.  Persons  who  claim  to  have  been  cured 
by  these  means  have  found  more  difficulty  in  es- 
caping from  the  specific  than  from  morphin.     Elab- 


192  Morphinism 

orate  plans  of  treatment  in  which  drugs  are  given 
week  after  week,  each  bottle  said  to  be  different 
from  the  other,  are  simply  the  withdrawal  plan  in 
which  morphin  or  some  form  of  opium  is  the  basis. 
These  alone,  without  other  treatment,  will  fail ;  and 
if  given  to  morphinists  indiscriminately,  no  matter 
what  the  conditions  are,  cannot  succeed. 

One  of  the  essentials  of  treatment  is  change  of 
surroundings  and  conditions  of  living.  The  with- 
drawal of  the  drug  demands  a  revolution  of  conduct, 
act,  and  thought.  New  scenes  and  surroundings  are 
helpful  for  their  diversive  effects.  The  mind  must 
be  led  out  of  itself  and  turned  away  from  old  condi- 
tions and  dependencies. 

While  home  treatment  is  possible  in  the  morphin 
addiction,  it  is  certainly  a  very  tedious,  long- 
drawn-out,  and  doubtful  experiment.  The  physi- 
cian cannot  give  the  attention  necessary  to  the 
patient,  and  the  patient  cannot  see  the  necessity  for 
a  trained  attendant  who  is  occupied  but  a  very 
small  part  of  the  time,  and  the  means  and  measures 
are  so  commonplace  that  the  patient  is  confident 
that  he  can  do  it  himself.  The  egotism  of  the  mor- 
phinist and  his  constant  introspection  make  him 
very  difficult  to  reason  with,  and  harder  to  manage 
in  familiar  surroundings. 

The  possibility  of  having  treatment  and  doing 
business  at  the  same  time  is  also  exceedingly  doubt- 


Treatment;  Asylum  Conditions  ;  Etc.     193 

ftil.  In  some  cases  it  is  urged  that  the  mental  diver- 
sion of  attending  to  business,  such  as  correspondence 
or  Hght  oversight  and  direction  occupying  only  a 
short  time  every  day,  may  be  helpful.  While  it  is 
possible  for  the  patient  to  abandon  morphin  under 
these  conditions,  it  is  not  likely  that  any  real  and 
permanent  change  will  be  accomplished.  The  mor- 
phinist must  give  up  all  work  and  business  and  place 
himself  in  the  hands  of  his  physician  if  he  would 
abandon  the  drug. 

The  after-treatment  with  most  men  may  be  equally 
perilous  at  home,  though  it  may  be  carried  on  with 
success  where  some  light  business  can  occupy  a 
small  part  of  the  time.  Each  case  should  be  gov- 
erned by  the  conditions  present  and  the  vigor  of  the 
patient. 

In  some  instances  travel  for  a  few  months,  visiting 
foreign  countries  in  a  leisurely  way,  is  the  best  possi- 
ble tonic  and  nerve  rest.  In  others,  it  is  the  worst 
experiment  that  can  be  made.  It  depends  upon  the 
condition  of  the  patient. 

For  some,  idleness,  seclusion  on  a  farm,  in  the 
mountains,  or  at  the  seaside,  removed  from  every 
form  of  excitement,  is  most  helpful. 

Professional  men  who  have  been  very  actively 

engaged,  and  can  only  be  contented  when  occupied, 

should  go  to  the  country  and  engage  in  horticulture, 

or  some  class  of  farming  that  would  divert  their 

13 


194  Morphinism 

energies  and  rouse  them  up  along  new  lines.  Often 
the  most  successful  cures  from  the  morphin  addic- 
tion have  been  attained  by  the  patient's  spending  a 
year  or  two  on  a  farm  or  in  the  mountains  away  from 
the  scenes  of  his  former  activities. 

A  chronic  morphinist  who  had  been  treated 
several  times  for  his  addiction,  and  had  relapsed  as 
often,  went  out  on  the  plains  and  became  a  cattle 
ranchman.  He  recovered,  and  is  now  a  strong, 
vigorous  man.  Others  have  gone  out  to  the  mining 
regions,  roughing  it,  Hving  under  greatly  changed 
conditions,  sleeping  in  the  open  air,  and  having  per- 
fect nerve  rest. 

A  noted  lawyer,  who  in  the  height  of  his  popular- 
ity suddenly  became  an  opium-taker  following  a  long 
addiction  to  alcohol,  after  treatment  went  out  on  an 
exploring  expedition  in  the  Government  service. 
The  change  of  scenery  and  methods  of  living,  with 
severe  muscular  exercise,  made  a  complete  revolu- 
tion in  his  life.  He  recovered,  abandoned  his  pro- 
fession, and  is  now  one  of  the  most  eminent  Govern- 
ment officials  in  the  geological  service.  Had  he  re- 
sumed his  profession,  relapse  would  probably  have 
followed  sooner  or  later. 

A  physician  who  was  a  morphinist  from  overwork 
and  exhaustion  tried  home  treatment  several  times 
without  success,  then  went  to  an  asylum,  and,  after 
restoration,  joined  a  surveying  party  for  a  new  rail- 


Treatment;  Asylum  Conditions  ;  Etc.     195 

road  in  the  far  West.  He  made  a  good  recovery, 
and  came  back  two  years  after,  resuming  his  pro- 
fession, and  is  now  a  leading  man  in  the  community. 
His  recovery  in  this  case  was  due  altogether  to  the 
long-continued  change  of  life  and  surroundings  in 
the  West. 

As  a  rule,  all  brain- workers  who  become  morphin- 
ists should,  after  withdrawal  of  the  drug,  give  up  all 
intellectual  work  and  become  muscle-workers  as  far 
as  possible  for  a  long  time.  Teachers  and  women, 
also  persons  with  highly  sensitive  nervous  organiza- 
tions, should  give  up  all  occupation  in  which  there  is 
strain  on  the  nervous  system. 

A  noted  New  York  merchant,  after  a  morphin 
addiction  of  two  years,  upon  recovery,  by  advice  of 
his  physician,  engaged  in  flower  culture,  superin- 
tending the  growth  of  plants  and  working  con- 
stantly, abandoning  all  his  previous  business  con- 
nections and  never  leaving  home.  In  this  way 
he  recovered,  and  resumed  business  two  years  later 
a  strong,  vigorous  man. 

Within  the  last  few  years,  through  the  advice  of 
physicians  a  number  of  morphinists  and  alcoholists 
of  wealth  have  been  persuaded  to  retire  to  the  coun- 
try, buying  abandoned  farms  in  New  England  and 
giving  their  time  and  energies  to  build  up  beautiful 
homes  and  farms.  In  many  instances  the  most  ex- 
cellent results  have  followed.     Many  have  become 


196  Morphinism 

restored,  and  are  now  valuable,  useful  citizens. 
Other  persons  of  this  class  have  gone  to  Florida 
and  the  southern  climates  and  have  engaged  in  fruit 
and  cotton  culture,  and  continued  strong  and  vigor- 
ous. This  change  is  the  best  possible  treatment  for 
a  large  class  of  persons. 


CHAPTER  VII 
OPIUM-TAKING;   ITS   PREVALENCE;    DIAGNOSIS 

Use  of  Opium.  Differs  a  Little  front  Morphin.  General  Symp- 
toms. Different  Opinions  of  the  Danger  of  Opium-taking.  De 
Quincey's  Delusions  a  Slow  Degeneration  Following  Its  Use.  The 
Psychic  Symptoms  Less  Prominent.  Pathologic  Symptoms.  Ef- 
fects on  Animals.  Opium-smoking;  Its  Fascination.  Number 
of  Persons  Suffering  from  Opium-smoking.  Prognosis.  General 
Treatment.  Delirium  from  This  Source.  Delirium  from  Mor- 
phinism. 

There  are  persons  in  almost  every  community 
who  use  opium  in  the  form  of  pills  or  powder.  Many 
of  them  never  come  under  medical  care  except  for 
derangement  of  digestion,  constipation,  and  general 
debility.  They  are  usually  neuropaths  and  elderly 
persons  suffering  from  various  troubles  for  which 
opium  is  found  to  give  relief.  Such  persons  have 
rheumatism,  neuralgia,  migraine,  hepatic  or  renal 
colic,  dysmenorrhea,  and  a  host  of  other  troubles. 
Others  use  opium  for  insomnia  or  to  lessen  grief  and 
mental  suffering,  giving  it  up  when  the  causes  dis- 
appear. In  many  instances  opium  is  used  as  a 
household  remedy  for  all  pains  and  discomforts,  and 
is  usually  abandoned  without  any  effort. 

There  is  no  doubt  that  from  these  sources  many 
persons  become  permanently  addicted  to  its  use. 

197 


198  Morphinism 

As  in  morphinism,  persons  with  a  neuropathic  dis- 
position have  a  continuous  craving  for  some  drug 
which  will  give  relief,  and  opium  is  found  to  accom- 
plish this  purpose  with  the  least  discomfort.  Often 
physicians  called  to  treat  some  acute  disease  find  the 
patient  to  be  an  opium  habitu6  of  long  standing.  In 
such  cases  several  difficult  questions  call  for  an 
answer:  Thus,  How  far  is  the  acute  disease  depen- 
dent upon  the  opium  used?  Can  the  disease  be 
treated  irrespective  of  the  opium  addiction?  Will 
the  removal  of  the  opium  complicate  or  diminish  the 
acute  affection? 

It  is  evident  that  the  treatment  of  acute  inflam- 
mations in  opium  addictions  is  unsatisfactory,  and 
that  such  cases  are  likely  to  end  fatally  under  any 
sort  of  treatment.  It  should  always  be  remem- 
bered that  in  these  opium  cases  there  is  retention  of 
effete  matters  and  states  of  poisoning  that  compli- 
cate all  forms  of  treatment.  The  accidental  or  occa- 
sional use  of  opium  may  continue  for  years  before  it 
develops  into  an  addiction.  Many  persons  use  opium 
at  intervals  for  many  widely  diverse  conditions,  giv- 
ing it  up  without  suffering  and  resuming  it  again  for 
real  or  imaginary  causes.  Others  use  opium  in 
small  quantities  daily,  never  exceeding  a  certain 
amount.  In  such  instances  there  are  few  symptoms 
to  indicate  the  condition  except  general  anemia, 
mental  listlessness,  with  a  disposition  to  sleep.     Un- 


Opium-taking — Prevalence;  Diagnosis    199 

less  morphin,  spirits,  or  cocain  are  used,  associated 
or  alternated,  the  person  is  able  to  continue  the  use 
of  opium  without  much  change  of  his  accustomed 
manner  of  living.  Gradually  changes  of  the  higher 
moral  faculties  become  apparent.  Somnolence,  ir- 
ritability, peevishness,  and  dishonesty  in  little  mat- 
ters appear,  the  last  particularly  where  it  concerns 
the  use  and  procuring  of  the  drug. 

Where  opium  has  been  used  a  long  time,  changes 
of  the  skin  appear ;  a  yellow  parchment-like  color  is 
characteristic,  with  cutaneous  eruptions  and  change 
of  color  of  the  hair  and  a  general  worn,  exhausted 
appearance.  In  many  persons  these  and  other 
symptoms  are  so  prominent  as  to  be  called  opium 
cachexias.  They  are  practically  described  in  the 
term  marasmus,  and  may  go  on  for  many  years,  sud- 
denly terminating  in  fatal  pneumonia,  gastritis,  or 
erysipelas. 

It  is  also  clear  that  opium  habitues  do  not  have 
the  same  mental  disturbances  noted  in  morphinism. 
Instead  of  stimulation  and  exaltation  there  is  quiet- 
ness and  mental  rest;  seldom  any  agreeable  visions 
and  pleasing  hallucinations  or  periods  of  vivid 
imagination  fill  the  mind.  De  Quincey's  experience 
of  soaring  to  Alpine  heights,  of  time  annihilated  and 
eternity  present,  and  the  recollection  of  events  of 
the  past  all  passing  through  the  mind  with  intense 
vividness'  and  pleasure,  are  practically  unknown  to 


200  Morphinism 

the  opium-taker  of  to-day.  On  the  contrary,  the 
opium  habitu^  rarely  experiences  more  than  a  sense 
of  good  feeling  and  comfort.  All  physical  and  men- 
tal unrest  disappears  and  a  torporous  state  of  quiet 
supervenes.  In  some  cases  short,  fitful  sleep  is  ac- 
companied with  transient  dreams  of  joy  or  suffering. 
After  a  short  time  these  pass  away,  then  only  ob- 
livion and  euphobia  follow. 

When  the  drug  is  withdrawn  in  the  early  stages, 
general  malaise,  headache,  and  nausea  follow.  These 
are  at  first  removed  by  coffee,  soda,  or  spirits.  After  a 
time  these  symptoms  increase  to  such  an  extent  and 
become  so  painful  that  the  drug  is  resumed.  Many 
persons  have  such  confidence  in  the  power  of  opium 
to  remove  all  painful  symptoms,  whether  from  its  use 
or  other  causes,  that  they  take  great  pains  to  keep  a 
quantity  concealed  about  their  person.  When  opium 
has  been  used  many  years  and  chronic  conditions 
follow,  general  feebleness  of  the  muscular  system  and 
tremors  are  common.  Some  authorities  believe  that 
in  these  cases,  if  the  superficial  reflexes  are  absent 
there  is  impending  ataxia  and  neuritis.  Many  of 
these  chronic  cases  have  muscular  disturbances 
which  closely  resemble  pronounced  ataxias.  The 
heart  also  exhibits  functional  and  organic  changes, 
and  attacks  of  pseudo-angina  pectoris,  with  general 
precordial  anxiety,  are  common  symptoms  in  the 
later  stages. 


Opium-taking — Prevalence  ;  Diagnosis    201 

The  opium-taker  is  less  secretive  and  more  bold, 
and  has  less  pride  of  character  after  a  long  use  of  the 
drug.  In  the  treatment  the  same  general  measures 
are  to  be  used  as  in  morphinism,  only  more  special- 
ized, and  varied  according  to  the  necessity  of  the 
case.  The  rapid  or  slow  withdrawal  is  to  be  deter- 
mined from  the  history  and  condition  of  the  patient. 
Thus,  in  one  example,  a  man  who  had  used  opium 
for  twenty  years  and  whose  mind  was  somewhat 
disturbed,  the  opium  was  removed  at  once.  The 
shock  to  his  nervous  system  and  the  suffering  which 
followed  produced  an  antagonism  and  disgust  for 
the  drug  which  were  very  effectual.  In  another 
instance  of  about  the  same  character  the  opium  was 
removed  in  gradual  stages,  with  much  less  suffering 
and  equally  good  results. 

In  many  instances  the  reduction  of  opiiun  beyond 
a  certain  point  is  a  question  of  great  practical  im- 
portance. Thus,  in  old  age  and  some  forms  of 
chronic  disease,  and  where  the  drug  has  been  used 
for  many  years  without  any  serious  injury,  the 
question  of  complete  withdrawal  is  one  of  doubt, 
particularly  where  the  possibility  of  relapse  is  almost 
certain  from  the  conditions  which  will  follow  its  re- 
moval. It  is  also  a  question  whether  life  may  not 
be  prolonged  by  small  doses  of  opium  given  regu- 
larly with  great  attention  paid  to  the  elimination  of 
the  poison  products. 


202  Morphinism 

The  English  Opium  Commission  brought  out  many 
very  curious  facts  supporting  the  statement  of  the 
conservative  properties  of  opium.  Sir  WiUiam 
Roberts  affirmed  that,  among  the  twenty  or  more 
active  principles  or  alkaloids  of  opium,  narcotin  or 
anarcotin  had  a  real  tonic  value.  It  has  been  as- 
serted that  opium  in  which  this  alkaloid  was  promi- 
nent is  an  antiperiodic,  and  can  be  used  with  little  or 
no  danger  with  the  same  frequency  as  quinin.  It  is 
evident  that  some  of  these  alkaloids  have  some  value 
which  is  yet  to  be  studied.  This  fact  would  explain 
.  the  possibility  of  the  crude  opium  in  gimi  or  powder 
being  used  so  long  without  marked  poisonous  effects. 

Whatever  course  may  be  followed  in  the  with- 
drawal or  medical  treatment  of  these  cases,  there 
should  be  a  thorough  recognition  of  the  two  condi- 
tions present — namely,  starvation  and  poisoning. 
Both  states  may  exist  in  varying  degrees,  and  all 
remedial  measures  should  be  directed  to  overcome 
or  lessen  them.  The  opium-taker  is  very  susceptible 
to  spirits,  and  will  very  often  abandon  the  drug  and 
become  an  alcoholic;  hence  the  danger  of  using 
remedies  containing  spirits  or  alcohols. 

The  opium-eater  rarely  consumes  such  large  doses 
as  the  morphinist.  Most  chronic  habitues  seldom 
consume  more  than  ten  or  twenty  grains  a  day. 
In  exceptional  cases  double  and  triple  this  quantity 
may  be  used,  but  not  for  any  length  of  time.     There 


Opium-taking — Prevalence  ;  Diagnosis    203 

is  in  these  large  doses  much  danger  from  a  cumula- 
tive action,  and  sudden  deaths  are  common.  In 
doses  of  from  five  to  ten  grains  many  persons 
live  on  for  years  with  only  general  symptoms  of 
progressive  decline  of  all  the  organic  functions,  be- 
ginning with  the  higher  moral  brain  and  extending 
down  to  the  other  organs. 

There  are  some  distinctions  worth  noting  between 
the  physiologic  effects  of  opium  and  morphin.  While 
in  a  general  way  there  are  many  resemblances,  par- 
ticularly in  the  termination,  yet  the  beginning  and 
progress  vary  widely. 

The  Chinese  nation  has  for  centuries  used  opium 
until  it  has  become  a  national  addiction.  There 
seems  to  have  been  no  special  racial  degeneration  due 
to  this  source,  but  we  know  very  little  about  the 
heredity  and  environments  of  this  race. 

Apparently  in  all  cases  the  use  of  opium  is  followed 
by  a  subjective  state  of  mind  making  the  sensations 
of  life  pleasing  and  satisfactory  for  a  time.  This 
euphobia  following  the  use  of  opium  is  more  or  less 
stationary  for  several  hours,  during  which  a  degree 
of  serenity  and  equipoise  of  all  the  faculties,  active 
or  passive,  that  relate  to  the  temper  and  moral  feel- 
ings exists.  Sometimes  the  imagination  is  stimu- 
lated for  a  brief  time  and  runs  on  in  a  dreamy,  vision- 
ary way.  Not  infrequently  the  intellect  seems  ex- 
alted for  a  time,  but  this  is  at  the  expense  of  its 


204  Morphinism 

strength  and  endurance.  It  is  very  doubtful  if  any- 
one under  the  influence  of  opium  is  capable  of  greater 
intellectual  vigor,  although  it  may  appear  to  be  so. 

The  idealization  which  De  Quincey  gathered  about 
opium  has  been  misleading,  and  undoubtedly  has 
done  a  great  deal  of  damage.  As  in  morphinism,  the 
higher  ethical  senses  of  the  opium-taker  are  soon  im- 
paired. Volition  is  diminished  and  the  capacity  for 
active  muscular  exercise  or  energy  of  any  sort  is  les- 
sened. The  appetite  is  disturbed  and  nearly  all  the 
functional  activities  are  lowered.  Mentally  there 
seems  to  be  a  sort  of  automatism,  in  which  impres- ' 
sions  and  thoughts  of  the  past  come  to  the  surface 
and  remain  for  a  time.  No  new  thoughts  or  new 
levels  of  intellectual  activity  are  attained,  and  one 
of  the  most  marked  conditions  is  that  of  a  tendency 
to  live  apart  from  others,  to  shun  companions,  to 
avoid  social  engagements,  and  to  ignore  comradeship 
or  natural  affection  for  those  who  are  entitled  to  it. 

If  he  is  found  in  any  company,  it  is  generally 
with  those  below  him  and  less  educated,  moral,  and 
refined ;  he  becomes  careless  of  the  decencies  of  life. 
A  degree  of  melancholia  comes  over  him  when  the 
effects  of  the  drug  pass  off.  He  sleeps  poorly,  has 
frequent  naps  and  fitful  spells,  loses  flesh,  his  relish 
for  all  exercise  and  activity  is  lost,  his  eye  becomes 
lusterless,  and  his  manner  and  air  are  cringing  and 
shrinking.     In  appearance  great  changes  take  place ; 


Opium-taking — Prevalence  ;  Diagnosis    205 

his  habits,  appearance,  and  clothing  show  indolence 
and  carelessness.  His  pride  of  character  is  lost,  and 
he  goes  shrinking  through  life  as  if  he  were  a  crim- 
inal, and  being  pursued. 

There  is  in  these  cases  a  steady  devolution.  In 
some  cases  it  is  slow  and  not  easily  recognized  at  first ; 
in  others,  rapid  and  marked.  The  morphin  case  is  on 
a  parallel  road.  The  effects  of  the  drug  are  stimulat- 
ing, satisfactory,  and  rapid.  There  is  at  first  a  sense 
of  completeness  and  satisfaction  and  an  egotistic  feel- 
ing that  the  brain  is  at  its  best,  that  intellectuality 
and  muscular  vigor  are  improved  and  some  condition 
of  ideal  health  has  been  created.  This  is  of  short  du- 
ration, and  is  followed  by  misery  and  wretchedness, 
which  demand  a  repetition  of  the  drug  before  relief 
can  be  obtained.  The  will  sinks  rapidly  before  these 
physical  impulses  and  all  reason  is  lost  in  the  in- 
tensity of  the  desire  for  relief.  Where  the  drug  is 
injected  by  the  needle,  the  relief  is  so  rapid  and  the 
impression  so  pronounced  as  to  dominate  every  other 
condition. 

In  the  early  stages  the  system  remains  quiet  after 
the  opium  has  been  entirely  withdrawn,  and  only 
from  some  special  exciting  cause  does  the  desire  for 
the  drug  reappear.  Each  use  of  the  drug  is  followed 
by  greater  demand  for  it.  The  period  of  stimula- 
tion diminishes  and  the  exhilaration  and  comfort- 
able feelings  grow  less  and  less,  until  finally  the 


2o6  Morphinism 

drug  has  to  be  given  or  is  taken  at  rapidly  decreas- 
ing intervals. 

The  opium-taker  is  never  fully  conscious  of  the 
danger  of  his  addiction  or  the  damage  that  follows 
from  its  continued  use.  The  morphinist  after  the 
first  period  of  satisfaction  from  the  effects  of  the 
drug  is  filled  with  dread  at  his  condition.  He  will 
talk  about  stopping  and  of  the  misery  of  his  condi- 
tion, and  devise  means  and  methods  to  escape,  all 
of  which  will  fade  into  thin  air  when  the  effects  of 
the  drug  pass  away.  The  morphinist  often  attempts 
substitutes,  and  will  enthusiastically  try  new  reme- 
dies and  specifics,  and  will  reason  with  some  acute- 
ness  about  his  condition,  then  relapse  to  the  drug 
with  the  slightest  temptation.  On  the  other  hand, 
the  opium-taker  has  no  dread,  never  uses  substi- 
tutes or  new  remedies,  and  makes  no  effort  to  give 
up  the  drug. 

Intellectually,  the  morphinist  may  appear  less 
affected  than  the  opium-taker,  and  may  be  able  to 
conceal  the  condition.  Beyond  this  the  nutrition 
suffers,  the  energy  of  the  brain  is  lessened,  and 
states  of  starvation  and  intoxication  are  always 
present.  Many  symptoms  which  were  seen  in 
opium-eaters  appear  in  more  aggravated  character. 
In  the  opium  case  dementia  and  melancholia  are  the 
common  sequels.  The  opium-eater  may  go  on  for 
a  number  of  years  without  any  special  suffering  or 


Opium-taking — Prevalence  ;  Diagnosis    207 

changes;  while  the  morphinist  sooner  reaches  the 
end  of  his  career  in  some  final  break-up  and  death. 

Dr.  Tauszk  calls  attention  to  the  fact  that  great 
caution  is  necessary  in  giving  opiates  to  old  people. 
He  noticed  that  doses  of  ^  to  |  of  a  grain  of  morphin 
are  frequently  followed  by  symptoms  of  intoxication, 
such  as  nausea,  difficult  breathing,  contraction  of  the 
pupils,  headache,  paleness  of  the  face,  and  difficult 
micturition.  According  to  this  author,  old  people, 
especially  those  with  arteriosclerosis,  have  a  special 
intolerance  toward  morphin.  When  giving  opiates 
to  old  people  for  the  first  time,  the  dose  of  morphin 
should  be  T^  of  a  grain,  and  of  opium  ^  to  ^  of  a 
grain.  Hypodermically,  morphin  should  be  given 
to  the  aged  only  after  we  are  sure  that  they  have  no 
intolerance  for  the  drug. 

The  pathologic  changes  observed  in  different  forms 
of  opiumism  are  limited  and  very  indistinct.  The 
shrunken  livid  appearance  of  the  patient  is  a  fair 
representation  of  his  internal  physical  strength.  The 
repeated  contraction  of  the  vessels  and  continuous 
narcotism  constantly  impair  the  nutritive  processes 
and  pervert  vital  functions.  Anemia,  both  psychic 
and  physical,  is  present. 

Organic  lesions  are  common.  Even  when  pre- 
mature (ieath  ends  the  succession  of  alternating 
hyperesthesias  and  anesthesias,  the  condition  is 
probably  that  of  paralysis.     The  nerve  exhaustion, 


2o8  Morphinism 

the  impairment  of  the  circulation,  the  general 
wasting  and  emaciation,  are  all  prominent  links 
in  the  chain. 

The  physiologic  action  of  morphin  and  the  symp- 
toms are  practically  the  same  as  those  of  opium 
cases.  The  tincture  of  opium  brings  with  it  alco- 
hol, which  modifies  in  some  degree  many  of  the 
symptoms  from  it,  but  the  narcotic  effects  are  prac- 
tically the  same. 

Opium-smoking  seems  to  differ  from  other  forms 
of  addiction  in  its  intoxicating  qualities.  In  this 
form  opium  is  less  stimulating  than  morphin  and 
has  a  dreamy,  sedative  action,  followed  by  very 
peculiar  symptoms.  The  morphinist  wishes  to  be 
alone  to  enjoy  his  drug;  the  opium-smoker  differs 
from  him  in  a  peculiar  manner,  and  wants  company, 
is  talkative,  his  mind  turns  in  a  philosophic  direc- 
tion, to  monosyllabic  comments  on  men  and  events. 
He  goes  to  a  "joint,"  or  a  room  which  persons  with 
similar  desires  frequent.  Here,  reclining  on  a  bench 
or  a  table,  he  inhales  the  vapors  of  burning  opium 
and  is  immediately  at  peace  with  every  one.  A 
dreamy  satisfied  mentality  follows,  which  merges 
into  sleep.  This  is  short  and  fitful,  followed  by 
dreamy,  waking  periods,  during  which  more 
opium  is  inhaled.  Mentally,  intense  satisfaction 
and  serenity  prevail.  No  opposition  is  worthy  of 
notice.     He  has  no  conflicts,  only  an  intense  desire 


Opium-taking — Prevalence;  Diagnosis    209 

to  be  at  peace.  From  this  point  of  view  he  looks 
out  upon  the  world,  commenting  on  the  folly  of 
strife  and  agitation.  With  him  there  is  no  thought 
of  to-morrow,  no  duty  of  the  present.  It  is  one 
serene,  placid  calm  in  which  all  the  functions  of  the 
body  are  at  rest.  There  are  no  standards  of  ethics  or 
morality  to  live  up  to.  There  is  no  motive  and  pur- 
pose worth  a  strain  or  an  effort  to  accomplish.  An 
elysium  has  been  reached.  All  sense  of  time  and  all 
proprieties  and  obligations  are  forgotten.  He  has 
no  object  except  to  continue  this  blissful  state.  In 
a  low,  monotonous  voice  the  habitu6  dwells  on 
great  deeds,  and  boasts  of  mental  strength  and  what 
he  has  done  or  can  do,  generally  treating  most 
themes  with  a  lofty  indifference  and  a  far-away, 
dreamy  interest.  Thus  nodding,  sleeping,  and  wak- 
ing, and  alternately  fixing  his  pipe  and  inhaling 
its  fumes,  he  goes  on,  until  overcome  by  profound 
sleep.  When  the  effects  of  the  opium  wear  off  after 
sleep,  a  sense  of  misery  provokes  further  use  of  the 
pipe.  The  appetite  is  diminished,  and  bread  and 
coffee  at  long  intervals  are  quite  sufficient  to  satisfy 
the  hunger,  and  these  not  more  than  once  or  twice  a 
day.  The  excretion  of  the  kidneys  is  diminished 
and  the  bowels  become  sluggish.  All  hygienic  regu- 
lations as  to  ventilation,  exercise,  and  cleanliness 
are  ignored.  In  these  secluded  places  he  continues 
the  smoking  hour  after  hour  until  his  money^^gives 


2IO  Morphinism 

out  or  acute  nausea  comes  on.  Then  he  emerges, 
and  a  period  of  suffering,  cold  sweats,  and  depression 
follows,  from  which  he  recovers.  Other  drugs  will 
be  taken.  Frequently  alcohol  is  used  in  the  free 
interval.  Then  will  come  a  feeling  of  disgust  and  a 
desire  to  repeat  this  delirious  narcotism,  and  he  will 
disappear  in  an  opitun  resort. 

Opium  is  rarely  smoked  except  in  special  places 
provided  for  it,  for  several  reasons :  One,  the  peculiar 
odor  of  burned  opium  is  very  pungent,  and  readily 
betrays  the  victim  if  used  in  his  own  home.  Another 
is  that  the  opium-smoker  dreads  interruption,  and 
seeks  seclusion  where  there  is  no  possibihty  of  inter- 
ference until  he  has  become  surfeited.  The  opium 
resort  must  be  provided  with  experts  who  know 
how  to  assist  the  patrons  in  smoking  with  the  least 
discomfort  and  trouble.  The  foul  air  of  the  room, 
its  seclusion  and  removal  from  all  possible  detec- 
tion, and  the  dreamy,  stupid  patrons  make  it  very 
tmattractive  to  any  but  habitues. 

In  fashionable  circles  opium-smoking  is  in- 
dulged in  in  more  palatial  surroimdings,  but  the 
same  seclusion  and  same  desire  to  herd  together 
is  apparent.  Here  they  drowse  and  dream  and  sleep 
and  comment  in  a  most  optimistic  way,  and  then 
when  the  paroxysm  is  over  go  home  and  have  a 
period  of  wretchedness,  ending  in  recovery.  Most 
of  the  opium-smokers  have  rapidly  diminishing  free 


Opium-taking — Prevalence ;  Diagnosis    211 

intervals,  and  finally  are  obliged  to  smoke  every- 
day from  a  few  moments  to  an  hour.  Such  persons 
soon  become  pale,  anemic,  have  glassy  eyes,  cadav- 
erous skin,  and  a  generally  dry,  wrinkled  appearance. 
The  attempt  to  abandon  the  drug  is  followed  by 
substantially  the  same  symptoms  as  those  noted  in 
morphinism,  only  with  more  depression  and  less 
delirium.  The  opium-smoker  may  have  during  ab- 
stinence from  the  drug  a  vigorous  appetite  and  gour- 
mand tastes,  seeking  delicate  foods  and  drinking 
champagne  at  the  table,  but  when  using  opium  be- 
comes very  abstemious.  After  abandoning  the  drug 
he  has  dyspepsia,  is  melancholic,  and  presents  a  group 
of  psychic  symptoms  which  are  very  confusing. 
During  the  period  of  smoking  sexual  irritation  is  an 
occasional  symptom,  and  promiscuous  intercourse 
follows.  This  is  not  prolonged,  and  depends  largely 
upon  impulses  which  come  and  go  with  great  uncer- 
tainty. Not  all  opium-smokers  experience  the  same 
pleasing  effects.  Many  of  them  enjoy  the  stupor  and 
actual  cutting  off  from  all  thought  of  the  present  and 
past,  and  afterward  experience  very  unpleasant  sen- 
sations. While  there  are  the  same  ingenious  efforts 
at  concealment,  it  is  more  difficult  than  with  the 
morphin-taker.  After  a  short  time  the  physical 
effects  are  more  pronounced  and  difficult  to  cover 
up.  The  opium-smoker  dreads  morphin  by  the 
needle,  and  will  rarely  take  any  other  form  of  opium. 


212  Morphinism 

He  constantly  deludes  himself  with  the  idea  that  his 
addiction  can  be  stopped  at  any  moment.  Opium- 
smokers  of  the  better  classes  use  the  Turkish  and 
other  baths  to  counteract  the  effects  of  the  drug. 

In  many  circles  there  are  quite  a  large  proportion 
of  invalids  under  constant  medical  care  whose  dis- 
ability is  due  to  opium-smoking,  and  who  are  treated 
by  the  physician  constantly  for  the  after-effects. 
These  persons  frequently  die  of  acute  disease,  or 
when  injured  seem  to  have  no  resisting  power,  dying 
from  erysipelas,  tetanus,  or  low  forms  of  fever. 

In  chronic  cases  an  hour's  smoke  once  or  twice  a 
day  is  taken  to  keep  the  brain  and  nerves  quiescent 
In  other  and  more  recent  habitues,  one  smoke  a 
month  or  week  or  oftener  is  common.  Many  per- 
sons never  smoke  unless  exhausted  by  work  and 
care,  or  when  they  become  excited  and  irritated  or 
suffer  from  pain  and  some  special  disturbance  and 
discomfort.  Thus  clerks,  tradesmen,  hack-drivers, 
excitable  men  and  women,  become  prostrated  and 
visit  these  opium  resorts  for  rest  and  euphobia. 
Higher  up,  the  business  and  professional  man,  and 
the  idlers,  the  fast  women,  and  the  neurotic  fash- 
ionables, together  with  the  psychopath  ambitious 
for  money  or  for  fame,  find  relief  in  an  opium 
narcotism. 

There  is  in  opium-smoking  a  close  resemblance 
to  the  drink  paroxysm  of  inebriates :  when  the  nar- 


opium-taking — Prevalence;  Diagnosis    213 

cotism  passes  a  certain  point,  it  subsides,  and  a  free 
interval  follows.  As  in  inebriates,  the  free  interval 
becomes  shorter,  and  finally  disappears  altogether. 
The  opium-smokers  who  come  every  day  for  their 
narcotism,  either  from  poverty  or  disabiHty  after 
a  time  give  up  this  form  of  drug-taking  and  use 
laudanimi  or  spirits  or  both,  and  become  invalids, 
going  to  the  hospital  or  asylum.  If  alcohol-taking 
has  preceded  the  opium-smoking,  a  return  to  spirits 
is  certain  when  opium  is  withdrawn,  and  vice  versd. 

When  morphinists  have  been  opium-smokers  in 
the  past,  the  degeneration  is  greater  and  the  treat- 
ment is  more  prolonged  and  difficult.  The  nar- 
cotism from  the  fumes  of  opium  falls  most  heavily 
on  the  higher  brain-centers.  The  sense  of  duty 
and  the  relation  to  others,  with  consciousness  of 
right  and  wrong,  become  early  destroyed,  and  while 
automatically  thought  and  conduct  may  seem  to 
recognize  the  ethical  relations  of  things,  the  recog- 
nition is  superficial  and  imreal. 

Fortunately,  opiimi-smoking  is  not  always  pleas- 
ant, and  the  difficulties  surrotmding  its  use  prevent 
its  popularity.  The  desire  for  reHef  from  pain  can 
be  gratified  with  less  trouble  and  more  secrecy 
in  other  ways. 

A  number  of  persons  from  curiosity  have  become 
opium-smokers.  Finding  the  effects  of  opium  in  this 
way  fascinating,  smoking  has  been  continued  secretly. 


214  Morphinism 

An  example  was  brought  out  in  a  disputed  will  of  a 
man  who  had  for  twenty  years  used  opium  in  this 
way.  In  early  life  he  went  to  an  opium  resort  from 
curiosity,  and  ever  after  was  a  victim. 

In  the  treatment,  the  same  seclusion,  watchful- 
ness, and  medical  and  hygienic  care  are  essential. 
There  is  present  a  marasmic  condition  which  re- 
quires special  means  and  measures  suited  to  each 
case. 

The  prognosis  of  these  cases  is  more  grave  than 
that  of  morphinism,  especially  among  women.  The 
higher  brain-centers  seem  to  be  more  thoroughly 
broken  up,  and  the  power  of  control  more  feeble. 
The  motor  disturbances  in  these  cases  are  not  so 
pronounced  as  those  of  morphin.  There  is  rarely 
paresis,  ataxia,  or  tremors,  but  there  are  trophic 
derangements,  such  as  the  hair  becoming  white 
and  falling  out,  the  teeth  decaying  early,  and 
the  nails  of  the  fingers  becoming  brittle  and  crack- 
ing. Cutaneous  eruptions  are  common.  The  con- 
tracted pupil  frequently  ends  in  defective  sight. 
Congestions  of  the  head  and  lungs  are  not  tincommon. 
The  heart's  action  seems  to  be  lowered.  These 
symptoms  are  seen  often  in  morphin  cases,  hence 
they  are  all  of  the  same  class,  and  cannot  always 
be  distinguished  from  each  other. 

It  is  doubtful  whether  the  opium-smoker  exhibits 
as  much  cunning  and  mental  activity  as  the  morphin- 


Opium-taking — Prevalence  ;  Diagnosis     2 1 5 

ist.  His  intellect  seems  to  be  weaker,  the  disposition 
to  exert  himself  less.  Hallucinations  and  delusions 
are  not  common  except  on  certain  personal  subjects, 
particularly  that  of  being  able  to  conceal  his  condi- 
tion. The  opium-smoker  is  hardly  ever  an  open 
criminal.  He  may  steal  or  forge  papers,  but  his 
crimes  will  be  within  narrow  limits  and  never  seen 
in  any  act  that  requires  consecutive  thinking  or 
long  retention  of  an  idea. 

In  the  hospital  practice  of  large  cities  opium- 
smokers  come  for  treatment  of  diseases  of  the  stom- 
ach and  liver,  also  profound  anemia,  indigestion, 
and  general  brain  and  nerve  feebleness.  In  private 
practice  these  symptoms  are  noted  in  persons  who 
are  not  suspected  of  using  opium,  but  their  persist- 
ence notwithstanding  all  treatment  points  to  un- 
known causes,  of  which  opium-smoking  is  common. 

This  form  of  using  opium  is  increasing  in  large 
cities.  It  is  estimated  that  there  are  over  five  thou- 
sand opium-smokers  in  New  York  city,  and  in  other 
cities  the  numbers  are  equally  large.  The  majority 
of  these  victims  are  of  the  lower  classes,  persons  who 
are  spirit-drinkers  and  who  live  irregular  lives  of 
great  extremes,  also  persons  who  have  used  drugs 
for  relief  of  pain  and  discomfort.  In  the  higher 
classes  the  smokers  are  the  neurotics  and  nerve- 
exhausted  persons  and  idlers,  votaries  of  fashion, 
drinkers,  and  others  who  are  ever  seeking  to  gratify 


2i6  Morphinism 

the  senses.  The  first  class  are  found  in  secluded, 
miserable  resorts;  the  second  class  have  palatial 
club-rooms  fitted  up  for  this  purpose.  It  is  asserted 
on  good  authority  that  opium-smoking  is  growing 
very  rapidly  among  the  better  classes. 

Delirium  from  opium-smoking  is  comparatively 
rare,  and  often  is  attributed  to  other  than  the  real 
causes.  The  following  example  of  such  a  case  at- 
tracted much  attention  in  a  certain  medical  circle : 

An  invalid  lawyer  of  some  eminence  had  distinct 
periods  of  low  muttering  delirium,  which  came  on 
suddenly,  and  after  a  few  hours  or  a  day  passed  away. 
The  delirium  was  manifest  in  disconnected  utter- 
ances relating  to  fears  and  losses,  and  broken  pre- 
dictions of  sorrow  and  trouble.  His  voice  would 
begin  in  a  high  key,  and  very  shortly  after  would 
drop  to  a  whisper,  then  start  up  again,  but  would 
always  end  in  the  same  way.  Everything  referred 
to  the  past  or  future ;  the  present  was  not  spoken  of. 
The  diagnosis  was  doubtful,  until  finally  it  was  found 
that  he  was  an  opium-smoker.  These  attacks  of 
delirium  always  followed  periods  of  excessive  smok- 
ing, after  which  he  would  suffer  greatly  from  nausea, 
and  would  then  abstain.  The  delirium  would  follow 
a  few  hours  after  stopping  the  drug.  His  recovery 
was  always  attributed  to  the  means  used,  the  real 
cause  being  overlooked. 

A  patient  under  the  author's  care  had  an  attack  of 


Opium-taking — Prevalence;  Diagnosis    217 

delirium  of  twenty-four  hours'  duration,  apparently 
from  a  sudden  stopping  of  the  drug.  The  delirium 
was  of  the  low  muttering  type,  strongly  resembling 
that  of  typhoid  fever,  but  without  the  trembling  and 
with  much  less  prostration.  On  recovery  he  could 
not  recall  an)rthing  that  had  happened.  There  was 
no  muscular  agitation  nor  any  disposition  to  mania ; 
the  patient  simply  remained  passive,  uttering 
broken  sentences  in  whispered  tones. 

Several  authors  have  referred  to  a  new  form  of  de- 
lirium, with  these  symptoms,  occurring  in  invalids 
and  neurasthenics,  without  any  traceable  cause,  and 
the  condition  was  considered  due  to  a  toxemia  re- 
quiring sharp  eliminative  treatment.  All  other 
causes  were  thought  insignificant,  but  the  constant 
recurrence  of  these  deliriums  attracted  attention,  and 
revealed  an  opium  origin  hitherto  unsuspected. 
Such  deliriums  occur  in  recognized  neurotics  and 
general  invalids,  and  they  were  supposed  to  result 
from  functional  and  nutrient  disturbances,  and  to  be 
of  local  origin.  Undoubtedly  the  toxins  are  an  ex- 
citing cause;  but  the  changes  in.  the  neurons  and 
nerve-centers  due  to  the  narcotism  from  the  opium 
are  the  more  prominent  factors. 

In  one  reported  case  delirium  occurred  several 
times  during  a  single  year,  when  opium-smoking  was 
discovered,  and  the  discontinuance  of  the  drug  was 
followed  by  recovery.     In  a  recent  example,   an 


2i8  Morphinism 

invalid,  after  repeated  attacks  of  delirium  from 
which  he  partially  recovered,  finally  became  a  mut- 
tering dement,  talking  incessantly  and  groaning  as  if 
in  pain.  When  taken  to  an  asylum,  his  opium  addic- 
tion was  discovered.  The  family  physician  and  con- 
sultant had  failed  to  recognize  opium  in  the  causa- 
tion. 

The  clinical  fact  to  be  emphasized  is  that  any 
strange  low  form  of  delirium,  appearing  and  disap- 
pearing unexpectedly,  should  suggest  opium  addic- 
tion as  a  probable  cause.  While  other  and  less  ob- 
scure causes  may  be  followed  by  similar  forms  of 
delirium,  a  careful  inquiry  should  be  made  into  the 
surroundings  and  history  of  the  patient,  with  the 
purpose  of  excluding  opium  as  an  active  or  predispos- 
ing cause.  When  any  marked  type  of  delirium  ap- 
pears, and  continues  with  but  slight  changes,  there 
should  be  a  suspicion  of  the  concealed  use  of  opium. 
Delirium  of  other  forms,  approaching  imbecility, 
with  or  without  exacerbations,  should  also  call  atten- 
tion to  opium  as  a  possible  factor  in  the  cause. 

Old  men  and  women  who  have  used  opium  for 
years  frequently  have  a  similar  form  of  delirium, 
usually  occurring  some  months  before  death.  In 
these  cases  the  causes  are  known,  and  the  conditions 
which  follow  seem  but  the  natural  dissolution  of  the 
brain  and  nervous  system. 

A  number  of  cases  of  opitun-mania  have,  before 


Opium-taking — Prevalence;  Diagnosis    219 

the  drug  was  withdrawn  or  during  the  period  of 
withdrawal,  developed  distinct  symptoms  of  delir- 
ium tremens.  Dr.  Richardiere,  of  Paris,  has  men- 
tioned many  cases  of  this  class  in  which  alcohol 
was  used  before  the  opium  was  taken  or  during 
the  time  of  the  addiction.  The  delirium  tremens 
was  therefore  a  distinct  form  of  both  alcohol  and 
opium  disturbance.  But  in  cases  where  alcohol 
has  not  been  used,  the  development  of  muscular 
trembling  and  agitation,  with  delusions  of  attacks 
by  animals  and  persecution,  are  not  so  common  and 
are  more  difficult  to  explain.  Undoubtedly  this  con- 
dition is  due  in  some  measure  to  autointoxications 
and  local  defects  in  the  brain-centers.  The  deliri- 
ums are  practically  alike  in  having  for  their  objects 
loathsome  animals  and  terrifying  figures  and  shapes 
attempting  harm  to  the  patient. 

In  one  instance  during  the  withdrawal  period  the 
onset  of  delirium  was  checked  by  the  renewal  and 
increased  use  of  opium,  but  later  the  opium  was 
withdrawn,  delirium  returned,  and  the  patient  died 
suddenly.  Several  of  the  cases  of  this  class  have 
suddenly  taken  on  pneumonic  symptoms,  which 
were  followed  by  death. 

Delirium  without  muscular  trembling  is  very 
often  observed  in  the  withdrawal  period,  but  it  is 
generally  of  a  vague,  uncertain  character,  and  rarely 
is  confined  to  any  particular  idea.     Pneumonia  is  a 


2  20  Morphinism 

condition  which  may  follow  any  time,  and  is  proba- 
bly due  to  paresis  of  the  nerves  centering  in  the 
lungs.  Spasmodic  coughing  and  nervous  trembling 
are  no  doubt  due  to  injuries  of  some  local  centers. 

It  must  be  remembered  that  well-marked  cases 
of  delirium  tremens  in  opiumism  are  usually  fol- 
lowed by  death,  and  that  no  specific  treatment  or 
local  applications  can  often  avert  the  fatal  results. 
The  indications  therapeutically  are  those  for  sharp 
eliminatives  to  throw  off  the  ptomain  poisoning  or 
chemical  products  which  are  sources  of  poisoning. 

In  opium-maniacs  sudden  shocks  are  followed  by 
delirium,  and  the  possibiHty  of  this  symptom  break- 
ing out  any  time  is  always  to  be  considered.  Many 
persons  are  taken  to  insane  asylums  in  states  of 
violent  delirium  resembling  delirium  tremens,  and 
on  its  subsidence  are  found  to  be  opium-maniacs. 
Persons  arrested  on  the  street  as  disturbers  of  the 
peace  are  often  of  this  class ;  the  delirium  and  delu- 
sions do  not  pass  away,  and  they  are  judged  insane, 
and  often  sent  to  asylums,  where  they  die.  It  is 
then  discovered  that  they  were  opium-takers. 

A  prominent  man  developed  deHrium  tremens  in 
his  home.  He  was  supposed  to  be  temperate  and 
was  known  not  to  use  alcohol.  The  attending  physi- 
cian gave  him  large  doses  of  morphin  and  was  sur- 
prised at  the  toleration.  Alcohol  was  given  to  pre- 
vent collapse.     The  result  was  increased  delirium 


Opium-taking — Prevalence;  Diagnosis    221 

and  greater  prostration.  After  several  days  his 
secret  use  of  opixim  was  discovered,  and  eliminative 
treatment,  with  reduced  doses  of  opium,  cleared  up 
the  case. 

No  doubt  similar  cases  occur  in  which  opium  is 
not  given,  and  the  extreme  prostration  from  the 
withdrawal  of  the  drug  may  merge  into  other  and 
often  fatal  diseases.  In  delirium  tremens  with  ex- 
treme prostration  inquiry  should  be  made  about 
former  opiimi  addictions.  The  body  should  be 
examined  for  marks  of  the  needle,  and  when  its 
use  is  discovered,  the  treatment  will  be  different. 

Alt  has  pointed  out  the  fact  that  morphin  re- 
mains in  the  stomach  and  large  intestines,  from 
which  it  is  excreted  and  eliminated,  but  only  after 
some  time  has  passed.  This  was  proved  by  experi- 
ments on  dogs,  who  were  given  poisonous  doses  of 
morphin,  and  after  a  time  the  drug  was  washed  out 
of  the  stomach,  not  having  been  absorbed.  He  be- 
lieves that  only  when  large  continuous  doses  of  opi- 
um are  given  can  it  be  found  in  the  feces  or  urine. 
In  the  stomach  and  small  intestines  morphin  will 
be  found  in  all  cases  of  poisoning.  This  is  confirmed 
by  the  possibility  of  averting  poisonous  symptoms 
by  frequent  washing  of  the  stomach.  In  a  person 
who  has  used  morphin  for  any  length  of  time  there 
will  undoubtedly  be  present  a  large  quantity  of  the 
morphin  in  the  stomach  and  intestines,  and  some 


222  Morphinism 

time  will  elapse  before  it  will  be  all  absorbed  and 
taken  up  into  the  system.  Opium  in  the  powdered 
form  is  undoubtedly  not  retained  in  the  stomach 
and  bowels,  but  is  absorbed,  and  unless  used  in  large 
quantities,  is  not  found. 

It  is  a  curious  fact  that  but  few  animals  are  sus- 
ceptible to  opium.  Elephants,  horses,  dogs,  mon- 
keys, and  fishes  come  readily  under  the  influence  of 
alcohol,  and  many  representatives  of  the  brute 
creation  are  actually  poisoned  and  die  quickly  from 
it.  On  the  other  hand,  some  birds  and  other  animals 
thrive  on  opium.  According  to  Guinard,  morphin 
is  always,  in  all  doses,  an  excitant  and  convulsant  to 
the  cat.  This  is  manifest  by  agitation,  hyperex- 
citability,  hallucinations,  and  a  restless  stupor. 

Contrary  to  what  is  observed  in  many  animals, 
to  whom  the  drug  is  hypnotic,  morphin  will  cause 
the  pupil  to  dilate ;  the  respiration  and  the  heart  are 
accelerated ;  the  chilling  of  the  peripheral  parts  in- 
dicates vasoconstriction,  and  there  is  abundant  hy- 
persecretion of  saliva.  The  employment  of  large 
doses  produces  an  exaggeration  of  these  symptoms, 
with  convulsive  shocks.  When  the  dose  is  three-fifths 
of  a  grain  per  two  and  a  half  pounds  of  the  animal, 
it  is  usually  fatal,  death  coming  on  from  convulsions 
and  tetanic  rigidity.  Young  animals  are  less  sensi- 
tive than  old  ones,  while  all  animals  of  the  feline 
species  are  excited  by  this  drug. 


CHAPTER  VIII 

MEDICOLEGAL    RELATIONS    OF    CRIME    AND 
RESPONSIBILITY 

Faulty  Mind  and  Senses.  Some  Examples.  Loss  of  Conscious- 
ness. Moral  Palsy.  Untruthfulness.  Paralysis  of  the  Will. 
The  Questions  of  Responsibility.  Why  Morphinists  are  Irrespon- 
sible. Responsibility  in  the  Disposition  of  Property.  Responsi- 
bility in  Swindling  and  Fraud.  Selfishness.  Cannot  be  Trusted 
as  a  Witness.  Examples.  Need  of  Medicolegal  Study.  Some 
Strange  Cases.  Loss  of  Memory.  Not  Often  Used  for  Criminal 
Purposes.     Some  Examples. 

The  medicolegal  relations  of  morphinism  are  prac- 
tically unknown.  The  morphinist  is  unable  to  accu- 
rately describe  occurrences,  and  his  relation  to  them, 
because  of  physical  disability.  His  conceptions  of 
pain  are  very  largely  anticipative  and  imaginative, 
and  associated  with"mimicry. 

The  mind  seems  unable  to  analyze  the  impressions 
received  from  the  senses.  Pain  and  suffering  are 
so  vivid  to  the  patient's  mind  that  the  future  is  an- 
ticipated and  brought  to  the  present.  Facts  and 
conditions  are  impressed  so  vividly  on  the  mind 
as  to  become  exaggerated  and  distorted.  Hence, 
any  statements  concerning  both  objective  and  sub- 
jective matters  are   mixtures  of   fiction  and  fact 

which  cannot  be  discriminated. 

223 


2  24  Morphinism 

It  is  not  altogether  forgetfulness  or  stupidity  that 
makes  the  morphinist  incompetent.  His  mind  may 
be  active  and  work  logically  from  its  impressions, 
and  even  his  conclusions  from  given  premises  may 
be  correct,  but  his  conception  of  facts  and  ability 
to  determine  their  accuracy  is  faulty,  as  a  subjective 
impression  may  be  mistaken  for  an  objective  one. 
This,  with  the  egotistic  confidence,  makes  him  a 
dangerous  witness.  All  impressions,  even  if  unreal 
or  distorted,  are  accepted  without  question,  and 
grow  in  reality  the  more  they  are  considered.  Thus, 
a  suspicion  of  infidelity,  dishonesty,  or  intrigue  is 
accepted  as  a  fact,  and  a  clear  train  of  logical  reason- 
ing follows. . 

A  morphinist  after  reading  a  description  of  a 
prominent  man  who  was  a  defaulter  saw,  looking 
through  the  window,  a  man  passing  the  house. 
He  swore  on  the  trial  positively  to  the  identity 
of  the  man  with  the  criminal.  He  was  convinced 
of  the  accuracy  of  the  impression.  In  reality  the 
defaulter  was  in  a  distant  part  of  the  coimtry  at 
the  time,  and  the  morphinist  described  a  man  the 
counterpart  of  the  one  of  whom  he  had  read.  This 
was  simply  a  projection  of  the  mental  image  of  his 
brain  upon  a  passer-by. 

A  morphinist  arrested  in  the  company  of  disrepu- 
table characters  where  a  murder  had  been  committed 
made,  at  the  suggestion  of  a  detective,  a  confession 


Medicolegal  Relations  of  Morphinism     225 

that  he  had  witnessed  certain  acts,  giving  minute 
details  which  in  reality  were  all  untrue.  It  was 
found  afterward  that  this  confession  corresponded 
in  detail  to  the  theories  the  detective  formed  before 
the  facts  were  known,  and  that  he  had  uncon- 
sciously suggested  to  the  morphinist  this  theory, 
which  was  accepted  and  described  as  a  statement  of 
literal  facts. 

In  the  making  of  wills  the  morphinism  of  the  tes- 
tator is  often  very  apparent  in  strange,  unreason- 
ing bequests.  Mixed  impressions,  both  objective 
and  subjective,  are  made  the  basis  of  reasoning  as 
to  duty  and  responsibility. 

A  morphinist  having  a  large  property  wrote  at 
intervals  different  wills,  each  one  logical  and  clear, 
and  yet  varying  so  widely  as  to  suggest  the  mental 
failure  of  the  testator.  After  death  the  will  pro- 
bated was  contested,  and  it  was  shown  that  he  was 
a  secret  morphin-taker,  and  although  his  general 
conduct  appeared  sane  and  his  reasoning  consistent, 
yet  his  impulses  and  prejudices  were  unreasonable, 
and  varied  widely.  He  was  unable  to  consistently 
determine  his  relations  and  duties  to  others. 

In  another  case  a  morphinist  conceived  the  im- 
pression that  his  partner  was  defrauding  him.  He 
executed  forged  papers  and  came  into  dishonest 
possession  of  the  capital  involved,  defending  his 
course  with  great  earnestness.  His  changed  manner 
15 


226  Morphinism 

and  habits  seemed  the  most  prominent  signs  of  men- 
tal failure.  A  careful  study  brought  out  the  fact 
of  delusional  suspicion  and  egotism. 

Criminal  assaults  have  been  committed  by  mor- 
phinists who  in  court  have  disputed  the  facts  so 
stoutly  as  to  create  many  doubts  of  their  guilt.  The 
impression  on  the  mind  of  the  morphinist  that  he  was 
incapable  of  committing  an  act  of  so  grave  a  char- 
acter becomes  a  fixed  conviction,  with  this  reserva- 
tion :  that  if  he  had  committed  the  act,  there  were 
extenuating  circumstances  and  justifiable  reasons  to 
explain  it.  Hence  defense  would  be  made  with 
earnestness  and  fervor.  Morphinists  may  display  a 
consciousness  of  criminal  acts,  but  think  they  were 
justifiable  and  could  not  have  been  otherwise.  Their 
denials  are  so  palpably  false  as  to  be  unmistakable. 

It  is  not  clear  why  the  morale  of  the  morphinist 
and  his  ethical  sense  of  right  and  wrong  should  be 
so  feeble.  It  is  characteristic  of  all  such  cases  to 
be  unable  to  be  truthful;  first,  in  regard  to  them- 
selves and  their  addiction,  and  then  concerning  their 
relations  to  others.  In  some  cases  this  moral  palsy 
may  be  limited  to  conduct  and  motives,  and  not 
be  seen  in  relation  to  matters  outside  of  their  own 
conditions. 

One  man  will  be  truthful  on  all  matters  except  his 
addiction  to  the  drug.  Here  he  will  resort  to  the 
most  senseless  lying,  and  make  cunning  efforts  to 


Medicolegal  Relations  of  Morphinism     227 

conceal  his  conduct  or  explain  it.  In  most  instances 
this  palsy  extends  in  the  later  stages  to  all  the  rela- 
tions of  life. 

It  may  be  stated  that  nearly  all  evidence  given  by 
a  morphinist  in  a  contested  case  in  court  is  unrelia- 
able.  The  exceptions  to  this  prove  the  rule.  It 
may  also  be  said  that  the  person  who  uses  mor- 
phin  by  the  needle  is  more  debilitated  mentally  and 
less  able  to  realize  his  exact  relations  to  others  and 
his  duty  and  responsibility. 

The  defense  of  the  influence  of  morphin  in  destroy- 
ing responsibility  has  recently  attracted  much  at- 
tention in  France.  A  distinguished  man  was  accused 
of  cruelty  to  his  young  child.  On  judicial  inquiry 
he  was  found  to  be  a  morphinist,  and  of  defective 
intelligence  and  control.  Medical  examination  was 
not  able  to  detect  insanity,  but  he  was  nevertheless 
sent  to  an  insane  asylum.  In  a  second  case  a  physi- 
cian killed  a  relative  without  reason  or  provocation, 
and  claimed  to  have  no  recollection  of  the  act.  He 
was  a  morphinist,  and  had  somnolent  periods  re- 
sembling trance  states.  During  this  condition  the 
crime  was  committed. 

These  cases  were  reviewed  by  Dr.  Guimbail,  with 
the  following  conclusions:  First,  morphin  causes 
defects  of  attention  and  paralysis  of  the  will.  Sec- 
ond, the  ethical  sense  to  distinguish  between  good 
and  evil  is  blurred,  and  the  victim  is  unable  to  dis- 


228  Morphinism 

criminate.  This  sense  is  lost  in  many  cases,  and|he 
cannot  act  from  any  moral  basis.  Third,  his  free  will 
is  lost  and  power  of  control  over  the  impulses  is  less- 
ened. Hence  he  is  dominated  by  morbid  impulses, 
both  physical  and  mental.  Fourth,  the  morphinist 
is  a  genuine  lunatic ;  as  much  so  as  the  dipsomaniac, 
only  more  subtle  and  concealed.  Fifth,  respon- 
sibility is  always  impaired  because  of  the  intellectual 
enfeeblement  and  diminution  of  the  moral  sense. 
This  is  more  apparent  when  associated  with  delusions 
and  mental  disturbance.  The  border-line  between 
responsibility  and  irresponsibility  can  never  be 
found.  Each  case  must  furnish  the  facts  from 
which  it  is  to  be  judged. 

In  a  recent  discussion  by  the  French  Society  of 
Psychology  the  question  of  responsibility  in  mor- 
phinomania  brought  out  the  following  statements: 
To  establish  the  capacity  of  a  morphinomaniac  all 
phases  of  the  disease  must  be  examined.  Each  case 
presents  phases  and  variable  degrees  of  resistance 
to  the  dose  employed ;  hence  there  must  be  different 
degrees  of  mental  condition.  There  must  be  periods 
of  absolute  irresponsibility  and  other  periods  of 
apparent  soundness  of  mind. 

One  author  was  convinced  that  morphinic  mania 
can  occur  in  a  case  only  where  there  is  an  established 
predisposition  to  become  irresponsible,  and  that  this 
could  not  be  created  in  a  healthy  brain  and  nervous 


Medicolegal  Relations  of  Morphinism     229 

system.  Exception  was  taken  to  this,  and  cases 
were  mentioned  of  an  acquired  disposition  which 
destroyed  the  capacity  of  the  victim  to  judge  of  the 
conditions  present  and  of  his  relations  to  them.  It 
was  asserted  that  morphinomaniacs  should  all  be 
considered  as  mad  in  varying  degrees  according  to 
the  case  and  the  conditions  present. 

All  statements  by  the  morphin-taker  about  mat- 
ters regarding  his  daily  life  are  sure  to  be  full  of 
errors,  not  only  from  faulty  memory,  but  from 
incapacity  to  discriminate  between  the  truth  and 
fiction  of  any  subject.  While  he  may  be  very  clear 
in  some  directions,  his  power  of  judging  the  meaning 
of  facts  is  disturbed,  and  while  his  mind  may  be  logi- 
cal, the  sense  impressions  are  faulty,  and  the  conclu- 
sions which  he  draws  will  have  a  large  personal  bias 
which  is  continually  shifting.  The  sense  impressions 
are  accepted  without  question  or  study.  As,  for 
instance,  a  woman  ironing  a  shirt  at  an  open  window 
seemed  to  a  morphin-taker  to  be  beating  another 
person.  A  man  with  a  stick  in  his  hand,  smoldng 
freely,  was  supposed  to  be  firing  a  gun,  the  stick 
being  considered  the  gun  and  the  tobacco  smoke 
the  result  of  the  explosion. 

For  a  short  time  the  users  of  morphin  may  appear 

very  clear  and  positive  in  their  convictions,  but  when 

.pressed  to  explain  them  show  signs  of  confusion.  The 

breaking-up  of  the  sense  impressions,  with  the  feeble- 


230  Morphinism 

ness  and  diminished  power  of  the  higher  brain  to 
recognize  the  ethical  relations  of  life,  make  it  evi- 
dent that  the  statements  of  morphin-takers  cannot 
be  relied  upon,  and  should  never  be  accepted  unless 
confirmed. 
/'■"TTecently  the  question  of  legal  responsibility  in 
/  persons  who  use  opium  or  morphin  has  come  into 
/   prominence.     Several  very  important  cases  call  for 
j    a  medical  decision  of  the  degree  of  responsibility  or 
1    irresponsibility  of  this  class  of  persons. 
^~   Questions  Hke  the  following  call  for  an  answer: 
How  far  is  a  morphinist  or  an  opium  habitu^  respon- 
sible for  and  conscious  of  his  acts?    Will  the  use  of 
opium  or  any  of  its  alkaloids  destroy  the  sense  of  right 
and  wrong  or  of  duty  and  obligation?     Will  the  con- 
tinued use  of  opium  so  disturb  the  reason  and  higher 
moral  centers  as  to  encourage  crime? 

One  of  the  common  clinical  facts  which  seems  to 
bear  on  these  questions  is  the^  uniform  untruthful- 
less^^^f  persons  using  these  drugs,  particularly  in 
regard  to  matters  concerning  themselves.  Like  the 
alcoholic,  the  intrigue  and  deception  is  often  coarse 
and  unskilful  in  its  plan  and  execution.  Obliga- 
tions of  honor  and  duty  to  society  are  overcome  by 
morbid  impulses  for  narcotism.  In  many  instances 
changes  in  the  higher  ethical  brain  are  apparent  only 
in  the  later  stages  or  when  subjected  to  some  special 
strain  or  pressure. 


Why  Morphinists  are  Irresponsible       231 

A  general  answer  must  be  made  to  this  question 
from  a  clinical  standpoint:  Is  there  any  special 
class  of  crimes  that  are  commonly  committed  by 
morphinists?  and,  if  so,  what  are  they? 

The  action  of  opium  and  morphin  on  the  brain 
and  nervous  system  is  that  of  a  narcotic  and  depres- 
sant, hence  crimes  of  violence  are  rarely  com- 
mitted, but  crimes  against  property  and  character, 
and  crimes  associated  with  selfishness,  skepticism, 
and  creduhty,  are  common.  The  following  are 
illustrations:  A  morphinist  disinherited  his  son 
because  of  the  latter's  skepticism  in  religious  matters. 
Another  man  left  his  home,  believing  his  family 
was  plotting  to  place  him  in  an  asylum.  Another 
forges  a  note  to  procure  money  which  he  does  not 
need.  Another  engages  in  swindling  operations  in 
which  he  consents  to  defraud  his  father.  Another 
becomes  a  kleptomaniac,  stealing  everything  that 
his  fancy  demands. 

These  are  crimes  of  selfishness  and  impulse,  and 
while  sometimes  associated  with  cunning  and 
design,  always  lack  the  motives  of  the  calculating 
criminal. 


WHY  MORPHINISTS  ARE   IRRESPONSIBLE 
There   are   various   physiologic   reasons   for   the 
assertion  of  irresponsibility  in  morphinism.     Con- 


232  Morphinism 

tinuous  narcotism  and  blunting  of  the  sensory  cen- 
ters impairs  the  power  of  reasoning  by  obscuring 
and  narrowing  the  impression  of  the  senses.  The 
morphinist,  as  well  as  the  opium-taker,  always  has 
diminished  and  disturbed  powers  of  seeing,  hearing, 
taste,  and  smell.  The  objective  world  is  not  cor- 
rectly seen.  The  functions  and  organic  activities 
of  the  brain  are  impeded  and  their  vigor  and  acute- 
ness  lessened.  The  waste  products  of  the  system  are 
increased,  and  the  power  of  elimination  is  retarded. 
Favorable  soils  are  formed  for  the  growth  of  toxins 
and  poisons  which  in  themselves  are  sources  of 
depression.  Disturbed  nutrition,  anemia,  and  ex- 
haustion are  common  symptoms  of  this  condition. 

Persons  suffering  in  this  way  cannot  have  a  clear 
recognition  of  the  nature  and  consequences  of  acts 
and  conduct.  Such  persons  act  automatically,  re- 
peating what  has  been  done  before,  but  when  con- 
fronted with  new  sets  of  facts  and  conditions,  are 
not  quite  able  to  realize  the  relations  of  right  and 
wrong.  All  opium  inebriates  are  controlled  by  an 
impulse  to  procure  the  drug  at  such  times  as  will 
best  serve  for  their  comfort.  Every  other  consid- 
eration is  subservient  to  this  impulse.  The  com- 
fort or  discomfort  which  comes  from  the  use  or 
absence  of  the  drug  is  always  attributed  to  other 
conditions,  hence  the  reason  is  perverted  and  sense 
activities  are  deranged. 


Why  Morphinists  are  Irresponsible       233 

These  degenerations  of  both  brain  and  sense  are 
attributed  to  outside  causes  and  surroundings, 
^  Egotism  and  pessimism  are  so  frequently  associated 
that  the  relation  of  both  subjective  and  objective 
conditions  and  events  is  confused  and  misunderstood. 
Where  the  quality  and  nature  of  conduct  and  acts 
come  into  question,  this  defect  is  very  apparent, 
and  will  often  vary  widely  with  the  psychologic 
conditions  of  the  person  and  his  surroundings. 

Recently  one  of  the  questions  of  responsibility 
which  came  into  prominence  was  the  disposition  of 
a  large  property  by  a  person  who  used  opium.  He 
was  a  merchant  and  had  used  morphin  for  five  years, 
and  was  induced  by  persuasion  of  his  sons  to  undergo 
treatment  in  an  asylum.  This  action  seemed  to  be 
his  motive  for  disinheriting  them.  He  urged  that  he 
could  recover  at  home,  and  that  it  was  a  hardship 
to  go  away.  The  morphin  was  withdrawn,  and  he 
continued  cheerful,  maintaining  the  former  pleasant 
relations  with  his  sons.  A  year  later  he  died  from 
an  accident,  and  a  will  was  found  giving  his  property 
to  his  daughters.  This  will  was  drawn  up  after  the 
return  from  the  sanatorium,  when  he  was  not  openly 
using  morphin,  and  was  apparently  in  full  possession 
of  his  senses.  He  explained  to  the  lawyer  who  drew 
the  will  that  this  disposition  had  been  determined 
a  long  time  before,  and  grew  out  of  want  of  con- 
fidence in  his  sons.     In  a  careful  study  it  was  found 


234  Morphinism 

that  morphin  had  been  given  for  neurasthenic  states 
some  years  before,  and  had  been  continued  in  in- 
creasing doses  up  to  the  time  of  entrance  into  the 
asylum.  Soon  after  he  began  to  use  morphin, 
delusions  of  losing  his  property  and  fears  of  loss  by 
fire  or  burglars  grew  constantly.  At  times  he  was 
excited  because  unusual  efforts  were  not  made  to 
avoid  these  dangers.  After  returning  from  the 
asylum  he  was  more  irritable  and  depressed  than 
ever.  The  strong  probability  was  that  he  began 
to  use  morphin,  although  this  was  concealed.  His 
intense  egotism  and  continued  denial  of  using 
the  drug,  even  when  it  was  in  his  possession,  were 
prominent  symptoms.  From  this  and  other  facts  I 
was  convinced  of  his  irresponsibility  and  mental  per- 
version at  the  time  of  writing  the  will. 

A  morphinomaniac  began  the  use  of  morphin 
eight  years  before,  for  relief  from  neuralgia  following 
an  attack  of  malaria.  He  continued  its  use  imtil  he 
was  taking  twenty  grains  a  day.  Except  occasional 
somnolence  and  short  periods  of  excitement,  he 
seemed  in  no  way  changed.  Suddenly,  without 
cause,  he  sold  out  his  business  and  property  to  a 
clerk  for  a  very  low  price.  His  family  applied  for  a 
guardian,  and  a  commission  was  appointed  to  ex- 
amine him.  His  changed  mentality  and  extra- 
ordinary care  of  his  business  at  times,  followed  by 
indifference  and  disregard  of  any  business  considera- 


Why  Morphinists  are  Irresponsible       235 

tions  at  others,  were  the  most  prominent  symptoms. 
He  also  had  delusions  and  fear  of  violent  death, 
and  would  not  ride  in  a  public  conveyance.  He 
thought  his  family  was  opposed  to  him,  and  wished 
to  have  him  die.  At  times  he  was  very  credulous 
and  emotionally  religious.  Then  he  would  be 
skeptical  of  everything  and  doubt  all  statements 
made.  The  commission  decided  his  mind  was  im- 
paired to  the  extent  of  being  unable  to  manage  his 
property,  and  judge  of  the  right  relations  to  his 
family. 

These  examples  are  given  to  show  that  in  the  care 
and  disposition  of  property  a  morphin-taker  is  most 
likely  to  have  impaired  mentality  and  be  unable  to 
reason  sanely,  and  to  understand  his  relations  and 
duties  to  others.  His  impressions  are  unstable  and 
his  reason  changeable.  Hence  he  is  not  likely  to 
act  consistently  or  rationally. 

In  criminal  acts  the  morphinist  and  opium-taker 
not  infrequently  engages  in  swindling  operations, 
deceptions,  and  frauds.  Only  a  few  cases  have  been 
contested  on  the  ground  of  irresponsibility.  In 
most  of  them  the  facts  were  not  studied  with  suffi- 
cient minuteness,  and  the  courts  decHned  to  recog- 
nize fine  distinctions  of  mental  health  or  to  permit 
innovations  in  the  ordinary  ruling.  In  one  instance 
a  morphin-taker  preferred  to  go  to  prison  rather 
than  have  a  defense  made  on  the  ground  of  his 


236  Morphinism 

addiction.  The  circumstances  were  these :  A  manu- 
facturer, fifty-four  years  old,  of  excellent  character, 
was  given  morphin  for  some  digestive  trouble.  The 
effect  was  so  pleasing  that  its  withdrawal  was  fol- 
lowed by  insomnia.  Hence  its  use  was  continued. 
A  needle  was  secured,  and  was  used  secretly.  Six 
years  afterward  he  was  tried  and  sentenced  to  prison 
for  forgery.  He  used  the  names  of  his  friends  on 
bank-notes  and  became  involved,  although  himself 
not  a  bankrupt.  The  forgery  was  unreasonable, 
and  without  special  motive  or  purpose,  and  want- 
ing in  the  usual  cunning  of  that  class  of  criminals. 
His  embarrassment  could  have  been  relieved  with- 
out resorting  to  forgery.  For  two  years  he  had  been 
forging  papers  and  notes  and  taking  them  up  before 
the  crime  was  discovered.  He  was  not  a  poor  man, 
and  did  not  seem  to  make  anything  by  these  efforts. 
He  did  not  try  to  explain  why  he  had  done  this, 
or  seem  to  realize  the  nature  of  the  act,  but  ex- 
cused it  in  a  childish  way  as  a  customary  business 
method.  His  mind  was  feeble,  and  he  displayed 
religious  delusions,  writing  frequent  letters  to  rela- 
tives who  were  dead.  To  his  family  he  was  re- 
ticent and'  suspicious,  rather  irritable,  but  always 
reserved  and  quiet.  There  was  undoubtedly  mental 
impairment,  and  a  degree  of  insanity  which  was  not 
recognized.  He  is  now  serving  out  a  sentence. 
Had  he  been  placed  in  an  asylum  and  properly 
treated,  recovery  might^have  followed. 


Why  Morphinists  are  Irresponsible       237 

Other  cases  of  opium  and  morphin  addictions 
exhibit  symptoms  of  intense  selfishness  which  rapidly 
merge  into  dishonesty  and  crime.  Often  such  per- 
sons show  veritable  deliriums  of  acquisitiveness. 
Their  relations  to  others  are  those  of  intense  selfish- 
ness with  constant  efforts  to  beg  and  borrow  or 
appropriate  everything  which  may  or  may  not  be  of 
use. 

Recently  such  a  person  died,  and  the  inventory 
of  his  property  showed  a  large  collection  of  miscel- 
laneous articles  which  had  been  borrowed  and 
stolen.  It  was  found  that  for  years  he  had  con- 
stantly begged  or  borrowed,  and  finally  stole  every- 
thing he  fancied.  The  foremost  thought  of  his 
mind  was  to  procure  something  for  nothing.  He 
was  shunned  by  his  neighbors  and  friends,  and  on 
several  occasions  arrested,  but  was  always  able  to 
prove  an  alibi.  There  seemed  to  be  no  object  in  his 
life  except  to  procure  morphin  and  go  about  appro- 
priating everything  that  he  wished.  He  possessed 
cunning  enough  not  to  steal  openly  or  go  out  at 
night,  and  when  confronted  with  his  theft,  always 
explained  that  the  articles  were  borrowed,  to  be  re- 
turned at  a  certain  time.  He  possessed  a  certain 
amount  of  intellectual  capacity,  talking  about  events 
outside  of  his  own  interests,  and  showing  a  percepf- 
tion  of  the  relation  of  surroundings  and  conditions 
due  to  ordinary  sanity. 


238  Morphinism 

Many  of  these  cases  pursue  a  Hne  of  conduct  that 
by  itself  is  thoroughly  criminal ;  the  evil  in  it  may 
be  skilfully  concealed,  but  it  always  approaches  the 
verge  of  criminality.  Their  relation  to  others  is 
that  of  intense  acquisitiveness  and  desire  to  make 
use  of  or  to  possess  everything  that  comes  their 
way.  The  possible  motive  behind  this  is  sometimes 
doubtful,  often  very  apparent.  In  one  case  it  is  the 
fear  of  poverty  and  distress  in  old  age.  In  another 
it  is  materialization  of  the  impression  that  the  hid- 
den motive  of  all  persons  is  to  get  from  each  other 
all  they  possibly  can,  and  that  all  the  relations  of 
society  and  business  turn  on  grasping  selfishness. 
Such  persons  are  always  slanderous,  untruthful,  and 
deceive  with  every  opportunity.  Crimes  of  minor 
character  are  committed  constantly.  The  only  fea- 
ture about  it  showing  intelligence  is  the  boldness  of 
denial  or  the  offered  explanations  of  the  act. 

An  example  of  such  a  case  was  that  of  a  mor- 
phinist who  had  originally  been  a  clergyman.  From 
ill  health  he  became  a  farmer,  and  had  used  morphin 
for  a  great  many  years.  At  his  death  an  inventory 
of  his  property  showed  a  large  collection  of  unusual 
articles  which  he  had  procured  in  some  unknown 
way.  An  effort  was  made  in  the  courts  to  identify 
these  goods  and  to  distribute  them  to  the  rightful 
owners.  He  was  frequently  seen  at  stores  and  auc- 
tion sales,  and  while  apparently  examining  goods 


Why  Morphinists  are  Irresponsible       239 

with  great  care,  he  seldom  piirchased  any.  Persons 
with  whom  he  was  associated  not  infrequently  lost 
knives,  handkerchiefs,  and  other  small  articles ;  and 
when  they  were  found  in  his  possession,  he  seemed 
pleased,  and  restored  them  as  a  mere  incident  not 
worth  an  explanation.  When  the  losses  were  larger 
and  created  distress  among  his  friends,  he  mani- 
fested  great  interest,  and  generally  succeeded  in 
finding  them  in  some  unusual  place.  In  manner  he 
was  reserved,  and  in  business  matters  very  exact 
and  honest,  and  yet  he  stole  and  concealed  every- 
thing which  could  be  easily  secreted.  To  his  inti- 
mate friends  he  was  known  to  be  using  morphin, 
and  although  at  times  peculiar,  he  preached  excel- 
lent sermons  occasionally,  and  was  in  every  other 
way  a  reputable  man.  There  seemed  to  be  no  con- 
sciousness of  the  nature  of  his  acts  in  appropriat- 
ing and  concealing  things,  but,  on  the  contrary,  he 
seemed  to  have  a  conviction  that  these  things  came 
through  a  legitimate  source. 

Another  example  is  that  of  a  tramp  printer  who 
had  a  mania  for  marrying  in  every  town  he  visited. 
He  used  morphin  constantly,  travehng  from  place 
to  place,  always  disguising  himself  and  chang- 
ing his  name.  He  appeared  to  be  well,  although 
very  reticent  and  secretive  in  his  habits.  He 
claimed  to  be  very  religious  and  a  literary  man,  and 
read  a  great  deal.     After  marrying  he  would  dis- 


240  Morphinism 

appear  and  repeat  the  same  thing  in  a  distant  State. 
The  quantity  used  finally  increased  to  such  an  extent 
that  he  lost  all  caution,  and  was  detected  and  sent 
to  State's  prison. 

Examples  of  this  class  have  many  surface  indica- 
tions of  sanity  which  are  largely  automatic,  yet  asso- 
ciated with  defects  of  reasoning  only  apparent  from 
critical  study.  The  shoplifters  and  sneak-thieves 
belong  to  this  class.  They  seem  to  study  the  ap- 
pearance of  honesty,  though  their  criminal  acts  lack 
cunning  and  exhibit  foolishness  in  an  unmistakable 
degree.  A  certain  number  of  these  persons,  where 
they  belong  to  the  families  of  the  wealthy,  are 
watched  and  guarded  by  their  friends;  others  go 
to  jail  and  become  criminal  rounders.  The  with- 
drawal of  morphin  reveals  their  real  condition  and 
indicates  a  degree  of  insanity  that  is  beyond  ques- 
tion. 


CAN  MORPHIN  INEBRIATES  BE  TRUSTED  AS 

WITNESSES? 

This  question  has  been  asked  and  answered  dif- 
ferently in  several  important  cases.  A  special  form 
of  the  question  has  come  into  prominence  with  a 
very  uncertain  answer — namely.  How  far  can  a 
morphinist  or  opium-taker  be  trusted  as  a  witness 
in  matters  in  which  he  has  no  personal  interest? 
The  best  judgment  of  experts  familiar  with  these 


Morphin  Inebriates  as  Witnesses        241 

cases  seems  to  be  that  the  statements  of  such  per- 
sons on  the  stand  should  be  considered  doubtful, 
irrespective  of  all  personal  interest  or  absence  of 
interest,  unless  confirmed  by  other  facts  and  strong 
circumstantial  evidence.  In  a  case  of  this  class  a 
morphin-taking  woman  swore  positively  that  she 
had  witnessed  an  assault.  In  reality  no  such  at- 
tempt occurred.  Her  statement  was  a  delusion  and 
misconception.  In  another  case  a  morphinist  law- 
yer swore  that  he  had  witnessed  a  certain  will  at  a 
certain  time.  It  subsequently  appeared  that  the 
will  was  written  years  before,  and  he  had  not 
seen  it. 

In  criminal  cases  the  reliability  of  the  witness 
is  the  turning-point  of  the  case.  If  the  witness 
should  be  a  morphin-taker,  the  possibility  of  error 
would  make  his  statements  very  doubtful.  The 
opinion  expressed  in  the  courts  recently  is  that  the 
use  of  morphin  does  not  impair  the  responsibility 
imless  the  drug  has  been  used  a  long  time  and  stages 
of  chronicity  have  been  reached.  Here  irrespon- 
sibility must  be  assumed  unless  the  general  conduct 
and  thought  indicate  sanity. 

It  is  also  claimed  that  in  periods  of  intense  irrita- 
tion and  delirium  following  the  removal  of  the  mor- 
phin where  the  mind  is  evidently  unbalanced,  degrees 
of  irresponsibility  may  be  inferred.  It  has  been  as- 
serted that  during  this  stage  crime  may  be  com- 
16 


242  Morphinism 

mitted  of  violent  character  and  irresponsibility 
can  be  established  by  prominent  symptoms.  The 
courts  so  far  have  not  recognized  this,  and  no  cases 
have  been  defended  along  these  lines.  Cases  have 
occurred  in  which  crime  was  committed  during  the 
removal  period,  but  no  attempt  has  been  made  to 
show  the  delusive  and  delirious  activity  of  the  brain. 

It  may  be  stated  as  a  fact  which  clinical  experience 
will  amply  sustain,  that  morphin  used  either  in  large 
or  small  doses,  depending  on  the  case  and  the  con- 
ditions, always  alters  the  reasoning  powers  and 
changes  the  sensory  activities,  and  is  always  fol- 
lowed by  intellectual  weakness,  with  diminished 
moral  sense  and  consciousness  of  right  and  wrong. 

In  disputed  cases  it  is  a  reasonable  procedure  to 
show  that  the  criminal  was  not  using  morphin  at 
the  time  the  crime  was  committed  or  was  not  in  a 
condition  of  morphin  delirium  due  to  its  withdrawal. 
In  these  instances  the  principal  fact  that  opium  or  its 
alkaloids  had  been  used  a  long  time  previous  should 
be  a  good  reason  for  inferring  mental  change  and  im- 
consciousness  of  the  nature  and  quality  of  the  act. 

The  disability  which  appears  in  these  cases  may 
be  concealed,  and  only  appear  under  the  strain  of 
peculiarly  exciting  circumstances,  or  it  may  appear 
prominently  at  the  beginning  of  a  case.  In  some  in- 
stances it  is  progressive  and  regular;  in  others  it  is 


Morphin  Inebriates  as  Witnesses        243 

irregular,  impulsive,  and  marked  by  long  halts  and 
changes. 

As  an  example,  a  man  of  previously  good  charac- 
ter sudden"^  descended  to  very  low  levels  of  intrigue 
and  moral  palsy.  Both  his  conduct  and  thought 
were  markedly  changed.  This  change  followed  the 
use  of  morphin  within  a  year  or  two  from  the  time 
of  its  first  use,  and  clearly  indicated  a  cumulative 
and  concentrative  action  on  the  higher  brain-centers. 
He  was  able  to  conduct  business  and  in  some  re- 
spects seemed  not  much  changed. 

In  the  case  of  the  printer  mentioned,  who  married 
with  every  opportunity,  the  injury  from  morphin 
seemed  to  be  concentrated  in  one  direction.  His 
body  and  mind  seemed  not  to  suffer,  and  his  ability 
to  work  remained  the  same.  In  a  noted  case  of  the 
abduction  of  a  child,  the  criminal  was  a  morphinist 
of  long  standing,  and  the  crime  was  a  sudden  impulse, 
without  purpose  or  motive.  His  real  condition  of 
insanity  was  apparent  after  the  first  few  days  in 
prison.  Often  the  real  defects  of  both  reasoning 
and  consciousness  are  concealed  by  delusions  of 
free-will  and  ability  to  act  differently. 


CHAPTER  IX 

MEDICOLEGAL   RELATIONS   OF  CRIME  AND 
RESPONSIBILITY— (Continued) 

Clinical  Histories.  Failure  to  Understand  the  Degree  of  Respon- 
sibility. History  of  Inherited  and  Acquired  Defects.  Psychic 
Palsies.  Crime  Instincts  Prominent.  Double  Personality. 
Strange  Delusions.  Hallucinations  and  Morbid  Impulses. 
Opium  Not  Often  Used  for  Criminal  Purposes. 

CLINICAL  HISTORIES 

Whenever  the  fact  of  an  addiction  to  morphin 
appears  in  a  disputed  case,  the  clinical  history  should 
receive  very  careful  study.  The  first  condition  and 
circumstance  in  which  the  drug  was  used  will  often 
throw  a  great  deal  of  light  on  the  direction  of  the  de- 
generation and  pathologic  changes  which  follow. 

After  the  drug  has  been  used  a  long  time,  certain 
local  injuries  and  impairments  of  function  will 
appear.  From  this  point  the  progress  can  be  traced 
down  through  successive  stages  made  prominent  by 
certain  disabilities  and  dissolutions ;  also  in  organic 
and  functional  changes.  From  this  study  the  in- 
juries and  irresponsibilities  will  appear  and  the 
impression  of  sanity  will  be  dispelled.     The  frequent 

statement  that  morphin  narcosis  can  be  repeated 

244 


Medicolegal  Study  of  Morphinomania     245 

continuously  without  injury  because  a  casual  observa- 
tion does  not  reveal  it  will  be  found  to  be  an  error. 
Crimes  and  questionable  acts  committed  by  morphin 
habitues  are  always  the  result  of  a  defective  and 
disordered  brain.  The  organic  basis  for  these  acts 
may  be  traced  in  many  cases.  The  question  whether 
these  changes  are  permanent  or  transient  can  like- 
wise be  settled  by  a  study  of  accurate  clinical 
facts. 

Up  to  this  time  the  clinical  facts  and  studies  of 
cases  sustain  the  assertion  that  morphinists  and 
opium-takers  should  be  classed  among  the  insane,) 
and  be  studied  as  members  of  the  neurotic  family. 
It  is  also  clear  that  in  all  such  cases  there  is  im-' 
paired  mental  and  physical  health,  organic  change, 
and  limited  responsibility. 

NEED   OF  MEDICOLEGAL   STUDY  OF  MORPHINO- 
MANIA 

Every  year  it  is  becoming  more  and  more  ap- 
parent that  some  authoritative  studies  should  be 
made  along  the  medicolegal  lines  of  this  subject. 
When  alcohol  is  used  alternately  with  morphin,  and 
crime  follows,  the  question  of  insanity  will  turn 
largely  on  the  effect  of  alcohol,  Morphin  will  not  be 
considered.  It  is  doubtful  if  any  one  can  use  either 
of  these  drugs  long  and  retain  his  reasoning  powers 
and  normal  sense  perception.     The  use  of  morphin 


246  Morphinism 

alone  may  be  continued  secretly  without  attracting 
much  attention  or  suspicion  of  mental  change.  The 
following  are  examples  of  this  class : 

A  woman  killed  her  infant  child  and  was  unable  to 
recall  the  act  or  explain  her  motive.  She  became 
a  maniac  shortly  after  being  confined  in  prison.  It 
was  found  that  she  was  a  secret  morphin-taker  and 
had  committed  the  crime  in  some  delusional  stage 
after  a  larger  dose  than  usual. 

In  another  case  a  man  convicted  of  incendiarism 
proved  to  be  a  morphinist.  After  the  use  of  the 
needle  he  had  a  mania  to  set  fire  to  property  and  to 
make  a  great  effort  to  extinguish  it,  concealing  his 
'crime  with  great  cunning.  When  fully  under  the 
influence  of  morphin,  he  would  with  great  secrecy 
start  a  fire  at  some  point  where  there  would  be 
difficulty  in  extinguishing  it,  then  give  the  alarm 
and  show  excitement  and  energy  in  the  endeavor  to 
put  it  out. 

In  another  case  a  secret  morphinist  traded  his 
property  for  mining  stock  which  was  worthless. 
Another  man  of  this  class  drew  out  a  large  bank 
accoimt  to  buy  a  machine  for  perpetual  motion. 

In  these  cases  the  legal  question  of  responsibility 
caused  a  great  deal  of  trouble,  and  was  unsettled. 
Fortunately,  the  removal  of  morphin  revealed  the 
suspected  insanity  in  some  of  them. 

In  another  case  a  man  whose  strange  and  eccentric 


Medicolegal  Study  of  Morphinomania     247 

conduct  indicated  his  use  of  morphin  became  an 
accessory  to  a  murder.  In  the  defense  which  fol- 
lowed it  was  proved  that  his  conduct  and  manner 
were  peculiar  before  the  act,  and  yet  a  leading 
specialist  swore  that  he  was  sane  and  understood 
the  nature  and  character  of  his  deeds. 

Persons  of  this  class  belong  to  the  neurotics  and 
psychopaths,  many  of  which  have  inherited  states 
of  nerve  and  brain  exhaustion.  Others  have  ac- 
quired feeble  and  unstable  brain-centers.  Opium 
or  morphin  not  only  covers  up  these  conditions,  but 
intensifies  them,  making  them  pronounced  para- 
noiacs  and  defectives.  These  cases  always  exhibit 
morbid  impulses  and  failure  to  recognize  duty  and 
responsibiHty  in  the  ordinary  matters  of  right  and 
wrong.  Crime  is  very  natural  from  this  condition, 
and  only  requires  special,  exciting  causes  to  pro- 
duce it. 

Such  cases,  if  studied  with  the  same  critical 
accuracy  as  other  diseases,  will  have  no  mystery, 
and  the  real  conditions  will  appear  beyond  all  ques- 
tion. The  rule  should  be  to  examine  the  crime, 
its  nature  and  circumstances,  from  these  going 
back  and  tracing  the  conditions  and  causes  which 
apparently  favored  and  led  up  to  it.  Where  mor- 
phin addiction  is  found,  the  physiologic  action  on 
the  mind  and  body  should  be  considered.  The 
first  use  of  the  drug,  and  all  the  causes  and  circiun- 


248  Morphinism 

stances  associated,  together  with  the  heredity  and 
states  of  disease  or  injuries  and  physiologic  changes 
which  have  affected  the  vigor  and  growth  of  the 
body,  these  will  indicate  the  origin  and  progress  of 
the  degeneration. 

From  such  facts  clear  indications  will  appear  of 
capacity  or  incapacity  to  realize  the  ethical  relations 
of  life.  Beyond  this  the  physiologic  question  of 
the  exact  injury  and  the  psychologic  indications  of 
how  far  the  ethical  sense  has  been  disturbed  will 
help  to  explain  the  physical  character  of  the  act 
committed. 

In  deductions  from  these  facts  authorities  will 
necessarily  differ ;  courts  will  also  differ,  depending 
on  the  theories  they  hold  of  the  relation  of  mind 
and  body,  and  of  the  cause  and  meaning  of  the 
facts.  The  physician  can  never  be  mistaken  in 
claiming  irresponsibility  if  the  history  and  facts  of 
a  case  show  a  long  addiction  to  the  drug.  While  the 
conditions  and  circumstances  and  symptoms  will 
vary  widely,  the  general  principles  remain  true  that 
the  use  of  morphin  always  impairs  the  consciousness 
of  right  and  wrong,  and  therefore  lessens  or  destroys 
responsibility. 

In  crime  following  morphinism  cases  of  double 
personality  have  been  noted.  Delusional  states 
were  present  in  which  the  person  acted  two  dif- 
ferent characters,  that  of  an  honest,  innocent  man. 


Medicolegal  Study  of  Morphinomania     249 

and  that  of  an  adroit,  bold,  and  unscrupulous 
swindler.  While  the  term  "double  personaHty"  de- 
scribes in  a  general  way  these  two  states,  it  is  mis- 
leading as  compared  with  other  conditions  called  by 
this  name.  The  morphinist  enters  upon  a  course 
of  adroit  deception.  Externally^  in  conduct  and 
appearance  he  is  a  thoroughly  honest,  open,  frank 
person ;  secretly,  he  will  commit  acts  of  meanness  or 
crime.  When  the  morphin  is  withdrawn,  the  con- 
cealed motive  is  apparent  and  the  childishness  and 
confusion  which  follow  indicate  the  instability  of 
the  brain.  Such  persons  are  recognized  in  criminal 
courts  as  a  most  dangerous  class  by  their  audacity, 
cunning,  and  utter  absence  of  conscientiousness. 

In  these  cases  morphinism  seems  to  stimulate  a 
pecuHar  crime  instinct,  probably  based  upon  some 
predisposition,  along  with  an  extraordinary  power 
of  concealment  and  capacity  for  deception.  The 
double  personality  appears  in  the  apparent  truth- 
fulness of  the  person,  who  defends  his  criminal  act 
without  the  slightest  consciousness  of  its  nature, 
apparently  believing  in  its  morality.  There  are 
evidently  present  states  of  poisoning  in  which  the 
psychic  functions  are  deranged  through  the  system 
being  saturated  with  morphin. 

The  term  psychic  palsy  seems  to  describe  this 
condition  in  a  measure.  The  former  personality  of 
the  person  is  lost.     Conduct  and  thoughts  appear 


250  Morphinism 

from  a  different  point  of  view,  and  vary  widely  from 
former  conditions.  New  purposes  and  new  motives 
foreign  to  any  previous  ones  appear.  The  strange 
mixture  of  cunning,  honesty,  and  reasonableness  is 
so  unusual  as  to  be  outside  all  known  theories  of  the 
condition  of  the  brain.  Some  examples  of  these 
cases  will  be  given : 

One  instance  was  that  of  a  woman  who,  after  using 
morphin  up  to  a  certain  point,  went  about  the  house 
secreting  things  of  value,  locking  doors  and  windows, 
putting  away  matches,  through  the  fear  of  robbers 
or  fire.  During  this  period  she  appeared  rational, 
talked  clearly  of  other  matters,  then  would  relapse 
into  her  former  indifference  and  be  unconscious  that 
she  had  exercised  any  unusual  caution. 

A  case  of  much  prominence  was  that  of  a  noted 
politician  and  banker,  who,  after  retiring  from 
business,  began  to  use  morphin,  following  the  con- 
stant use  of  spirits.  He  never  appeared  unusual  or 
mentally  disturbed  in  any  way.  In  his  family  he 
was  reticent,  and  slept  a  great  deal  at  night.  Finally 
he  was  detected  setting  fire  to  a  building.  He  was 
found  to  be  the  author  of  numerous  incendiary 
fires  in  the  villages  about.  He  would  go  to  a  distant 
town  and  rise  in  the  middle  of  the  night,  start  a  fire 
in  some  old  building,  and  return  to  his  bed  so  secretly 
as  to  prevent  all  suspicion.  He  was  finally  caught  in 
the  act,  and  although  stoutly  denying  it  and  ex.- 


Medicolegal  Study  of  Morphinomania     251 

plaining  his  presence  in  other  ways,  yet  was  unable 
to  establish  his  innocence.  An  examination  showed 
that  after  using  a  larger  dose  than  usual  at  night 
he  would  become  very  secretive  and  go  about 
stealthily,  walking  along  back  streets  and  avoiding 
all  publicity,  returning  in  an  hour  or  so  to  his  room 
with  the  greatest  caution  and  cunning.  When 
found  in  some  suspicious  place,  he  would  explain 
his  conduct  with  frankness  and  honesty.  For  a  long 
time  many  bams  and  outhouses  and  old,  worthless 
buildings  in  the  neighborhood  were  burned  up  by  in- 
cendiaries. He  was  suspected,  placed  on  trial,  and 
the  defense  of  insanity  failed.  The  experts  were  con- 
fused as  to  his  mental  condition,  most  of  them  con- 
sidering him  responsible.  He  was  sent  to  prison  and 
the  morphin  withdrawn,  when  his  real  condition  was 
apparent.  In  this  case  morphin  seemed  to  stimulate 
his  brain,  rousing  up  pyromaniacal  impulses  associ- 
ated with  unusual  cunning  in  concealing  his  conduct, 
which  was  probably  based  on  some  idea  of  advan- 
tage to  the  community  in  having  these  unsightly 
structures  burned.  When  the  morphin  was  re- 
moved, he  had  a  very  confused  recollection  of  his 
conduct,  and  no  clear  conception  of  what  he  had 
done.  There  was  no  malice,  he  having  set  fire 
to  a  building  of  his  own,  and  the  next  day  offered 
a  large  reward  for  the  person  who  had  committed 
the  act. 


252  Morphinism 

A  patient  under  the  author's  care  for  excesses  in 
spirits  suddenly  became  a  speculator,  buying  stocks 
on  a  margin.  Fortunately,  his  resources  were  lim- 
ited, but  the  mania  continued  in  lottery  tickets  and 
bucket-shop  ventures.  This  practice  was  foreign  to 
his  past  conduct  and  character,  and  was  unexplain- 
able  until  his  secret  morphin  addiction  was  discov- 
ered. He  was  treated  for  this,  and  two  years  after- 
ward began  a  career  of  cunning,  sharp,  dishonest 
speculations,  and  was  arrested.  On  trial  the  re- 
sumption of  the  morphin  addiction  was  shown,  but 
the  mental  power  and  skill  displayed  indicated  tm.- 
usual  ability;  he  was  finally  convicted  and  sent  to 
prison.  I  saw  him  later,  when  the  morphin  was 
taken  away,  and  the  evident  imsoundness  of  his 
mind  could  not  be  mistaken. 

Another  case  which  came  under  notice  was  that 
of  a  prize-man  and  graduate  of  a  college,  who 
married  wealth  and  spent  two  years  traveling,  then 
suddenly  began  a  career  as  a  confidence-man  and 
forger.  He  traveled  around  under  assumed  names, 
passed  bog^s  notes,  raised  checks,  and  when  caught 
gave  such  clear  explanations  as  for  a  time  to  disarm 
all  suspicion.  Finally  he  was  arrested  and  held  for 
trial.  As  long  as  he  could  procure  morphin  he  was 
calm,  clear,  adroit,  and  possessed  of  unusual  brain 
power,  but  after  his  sentence  and  removal  to  prison 
he  became  childish  and  feeble  mentally.     In  this 


Medicolegal  Study  of  Morphinomania     253 

case  the  morphin  developed  a  new  personality.  He 
talked  as  if  he  believed  most  firmly  in  the  honesty  of 
his  career,  and  never  doubted  his  disability  to  do  any- 
thing dishonest.  When  confronted  with  his  decep- 
tions, he  did  not  recognize  the  nature  of  his  conduct, 
but  showed  the  greatest  skill  in  justifying  and  ex- 
plaining it,  never  displaying  any  visible  consciousness 
of  the  dual  life,  but  always  appearing  honest  and 
frank  to  an  extreme  degree.  He  passed  a  forged  note, 
then  went  out  on  a  back  street,  changed  his  attire, 
put  on  false  whiskers,  and  came  back  on  the  street, 
walking  with  great  coolness.  He  went  into  a  store, 
bought  some  morphin,  and  then  purchased  a  pair  of 
shoes,  giving  a  forged  note,  as  before.  A  detective 
who  had  followed  him  closely,  arrested  him,  and  after 
a  short  examination  before  the  chief  of  police  he  was 
discharged.  His  earnest,  frank  manner  convinced  the 
chief  that  he  was  not  guilty.  The  next  week  in  a 
neighboring  city  he  did  the  same  thing,  was  arrested, 
and  discharged  as  innocent.  Finally,  a  detective 
followed  him,  and  found  that  he  was  constantly 
changing  his  attire  and  assuming  different  dis- 
guises ;  buying  cloths  and  other  things  which  were 
finally  pawned;  giving  checks,  some  good,  others 
bad;  making  deposits  at  banks  and  drawing  them 
out.  During  this  time  he  bought  morphin  freely, 
but  never  seemed  other  than  calm.  He  was  finally 
arrested,  and  after  serving  a  short  sentence,  dis- 


254  Morphinism 

appeared.  While  using  morphin  he  appeared  very- 
frank  and  open  in  his  manner  and  conduct,  espe- 
cially in  public  and  in  conversation  with  others. 
He  carried  cards  and  billheads  of  well-known  firms 
far  away,  and  represented  himself  as  a  member  of 
the  different  firms  or  as  a  traveling  man  connected 
with  them.  He  always  carried  an  overcoat  and  had 
facilities  for  suddenly  changing  his  attire  and  ap- 
pearance. There  seemed  to  be  no  consciousness  of 
duplicity  in  his  talk  or  conduct.  When  the  morphin 
was  taken  away,  the  very  opposite  appeared.  He 
was  remorseful  and  depressed,  timid  and  shrinking, 
displaying  his  motives  and  thoughts  in  a  most 
marked  way. 

Another  case  reported  was  of  equal  interest.  A 
series  of  very  remarkable  swindling  operations  was 
noted  on  the  Hudson  River  night-boats  and  Boston 
Sound  steamers.  The  detectives  were  unable  to 
fasten  the  crime  on  any  one  until  finally  a  young 
man  of  refined,  delicate  appearance  was  arrested 
for  passing  a  forged  check.  It  was  ascertained  that 
he  was  the  probable  author  of  all  the  swindling  for 
the  past  two  years.  He  was  a  morphinist,  and  had 
an  income  from  an  annuity.  He  spent  his  time 
traveling  around,  appearing  to  be  a  clergyman,  actor, 
or  business  man,  and  talked  freely  with  every  one, 
inquiring  very  minutely  into  the  personal  history  of 
prominent  persons  and  officers.  He  would  secure  ad- 


Medicolegal  Study  of  Morphinomania    255 

varices  on  brass  watches  and  bogus  diamonds,  pass 
worthless  checks  and  railroad  tickets,  solicit  loans 
and  give  as  security  worthless  bonds  and  stocks.  He 
would  buy  goods,  giving  bogus  checks,  and  receive 
money  in  return ;  show  bank-deposit  books  of  large 
sums  and  leave  them  as  security ;  make  the  acquaint- 
ance of  some  rich  man,  and,  after  swindling  him,  dis- 
appear. He  changed  his  costume  frequently,  wear- 
ing spectacles  and  false  whiskers  and  wigs,  appearing 
as  a  large,  fleshy  man;  then  wearing  half  military 
suits.  His  wardrobe  was  composed  of  a  great 
variety  of  theatrical  suits,  and  he  frequently  claimed 
to  be  an  actor.  In  jail  he  was  identified  by  many 
persons  as  having  assumed  different  disguises  and  de- 
frauded them  in  various  ways.  As  long  as  he  could 
procure  morphin  he  was  genial,  self-reliant,  and  very 
sincere.  He  never  seemed  to  be  deceitful,  and 
always  acted  and  talked  as  if  he  firmly  believed 
in  everything  he  said  and  did.  The  most  careful 
questioning  and  effort  to  induce  him  to  explain  his 
conduct  left  a  strong  impression  of  his  honesty, 
although  it  did  not  explain  his  life  and  conduct. 
The  detectives  called  him  an  honest  rogue  while 
using  morphin.  His  manner  on  the  witness-stand 
was  so  frank  and  candid  that  the  mystery  of  his 
conduct  deepened,  and  the  jury  was  half  inclined 
to  think  that  some  mistake  had  been  made.  He 
was  sent  to  prison  and  the  morphin  removed,  and 


256  Morphinism 

all  his  manner  changed.  His  artlessness,  clear 
thought,  and  talk  disappeared,  and  the  fawning, 
lying  hypocrite  appeared,  with  all  the  criminal  in- 
stincts. He  is  still  in  prison,  and  is  regarded  with 
much  suspicion  by  his  keepers. 

While  these  may  be  considered  extreme  cases, 
they  are  types  of  an  unknown  state  following  the 
use  -of  morphin.  From  inquiry  it  appears  that  mor- 
phin  criminals  are  regarded  as  the  most  dangerous 
by  police  authorities.  They  often  have  full  control 
of  their  nerves  and  can  act  a  double  part  so  cleverly 
as  to  disarm  suspicion.  Such  cases  are  bold,  de- 
fiant, and  adroit,  and  possess  a  rare  power  of  de- 
ception entirely  foreign  to  other  criminals.  This  is 
sustained  in  the  ordinary  medical  treatment  of  such 
cases.  The  cunning  deception  and  the  imconscious 
reasoning  and  concealment  of  their  plans  and 
motives  seem  to  point  to  some  psychic  palsies  of 
certain  brain  functions.  Where  a  patient  is  appar- 
ently suffering,  and  then  suddenly  becomes  cheerful 
and  quiet,  and  is  loud  in  his  protests  against  the 
suspicion  of  having  used  any  morphin,  some  condi- 
tion of  psychic  palsy  is  likely  to  exist  dating  from 
the  first  secret  use  of  the  drug. 

Innumerable  instances  of  the  most  cunning  in- 
trigue and  seductive  falsehoods  are  common  in  such 
cases.  They  act  and  talk  with  the  certainty  of  truth- 
fulness, and  seem  unconscious  of  the  deceptions  they 


Medicolegal  Study  of  Morphinomania     257 

practise  in  their  efforts  to  procure  and  conceal  the  use 
of  the  drug.  One  such  case  was  detected  by  examina- 
tion of  the  urine,  in  which  the  morphin  reaction  was 
found.  It  was  that  of  a  woman  of  great  respectability 
and  prominence  in  the  chtirch  and  society.  She  was 
suspected  of  using  morphin,  and  yet  it  was  impossible 
to  discover  the  way  she  secured  the  drug.  Her  earnest , 
emphatic  denials  were  clearly  the  result  of  abnormal 
mental  activity,  and  showed  some  obscure  palsy  of 
the  higher  centers.  Yet  during  this  period  she  went 
about  in  her  usual  way.  She  was  regarded  as ,  an 
earnest,  praying  Christian,  whose  high  ideals  of  truth 
and  honesty  were  beyond  question  or  suspicion.  This 
case  roused  some  bitterness  among  her  friends.  Her 
husband  and  family  could  not  believe  that  she  was 
guilty  of  deception,  and  when  the  morphin  in  the 
urine  was  detected,  thought  it  a  mistake.  She  finally 
went  to  a  secluded  place  in  the  country,  and  after 
a  time  the  morphin  reaction  symptoms  appeared. 
Then  all  her  former  self-possession  and  boldness  left 
her.  She  became  very  penitent,  and  was  a  different 
person  in  every  way.  The  mystery  of  this  decep- 
tion was  called  by  the  clergyman  "a  possession  of 
the  Devil."  It  was  a  state  in  which  reasoning  and 
consciousness  of  the  relation  to  others  were  sus- 
pended. Her  mind  was  concentrated  on  procuring 
morphin  and  concealing  its  use  from  others.  This 
dominated  every  other  consideration,  and  was  prob- 
17 


258  Morphinism 

ably  considered  a  sacred  duty,  to  be  carried  out 
above  every  other  thing. 

In  the  examples  of  the  two  swindlers  the  morphin 
seemed  to  rouse  a  mania  for  deception  and  a  double 
life.  The  gains  procured  were  of  minor  considera- 
tion and  the  greatest  pleasure  came  from  taking 
advantage  of  the  credulity  of  others.  In  another 
case  the  confusion  and  mystery  which  followed  the 
deception  seemed  to  be  the  most  enjoyable  part. 
This  person  would  stand  around  and  talk  about  the 
act,  and  show  sympathy  with  the  sufferers  from  the 
act  he  had  committed. 

Very  few  cases  are  noted  where  capital  crime  was 
committed  in  thes6  morphin  states.  Thefts,  swind- 
ling, and  general  deception,  with  concealment  of 
motives  and  conduct,  are  the  most  frequent. 

The  author  has  met  with  two  cases  where  a  mania 
for  writing  a  will  occurred.  Both  men  of  some 
property  made  from  seven  to  eight  wills  a  year  for 
several  years.  These  were  concealed.  At  the  death 
of  one,  the  wills  were  brought  to  light.  The  other 
recovered  from  morphinism  and  destroyed  those  he 
had  made.    — — — ^ 

The  ctmning,  skill,  and  ability  displayed  in  the 
deceptions  of  morphinists  are  frequently  based  on 
delusions  that  are  so  dominant  as  to  seem  real  and 
true.  No  idea  of  the  real  condition  or  the  danger 
of  exposure  is  apparent  to  them.     They  will  act 


Medicolegal  Study  of  Morphinomania    259 

only  as  persons  do  who  are  fully  convinced  of  the 
honesty  and  reality  of  their  intentions. 

A  noted  physician  under  the  author's  care  dis- 
played extraordinary  skill  in  concealing  his  real 
condition  and  was  not  fully  conscious  of  his  acts  or 
the  consequences.  Even  when  he  was  convicted  of 
his  deception  he  only  seemed  roused  to  greater 
efforts  for  concealment.  No  reasoning  or  counsel 
could  displace  the  mania  for  deception.  On  other 
matters  he  was  in  nowise  disturbed  mentally, 
reasoning  and  acting  with  excellent  sense  and  judg- 
ment. He  could  discern  motives  and  deceptions  in 
others,  but  was  unable  to  realize  his  own  condition. 
When  the  morphin  was  removed,  this  changed,  and 
he  realized  his  actual  state  and  acted  differently. 

In  another  case  a  man  of  noted  honesty  and  strong 
character  denied  all  use  of  morphin,  and  when  a 
quantity  was  found  on  him,  persisted  in  explaining 
it  in  the  most  adroit  way.  He  seemed  actually  to 
believe  his  own  statements,  and  could  not  be  con- 
vinced they  were  not  true. 

The  foolish  deceptions  of  alcoholists  are  quite 
different.  They  often  display  a  consciousness  of  their 
real  condition  and  the  concealment  they  are  practis- 
ing. The  alcoholists  are  frequently  weak  and  child- 
ish in  deception,  and  show  by  their  conduct  a  certain 
consciousness  of  their  danger  in  the  efforts  they  make 
to  cover  it  up. 


26o  Morphinism 

Certain  persons  who  use  both  morphin  and  spirits 
often  appear  to  be  thoroughly  impressed  with  the  idea 
of  the  correctness  of  their  acts  and  have  no  sense  of 
the  deception  and  danger  of  exposure.  It  wotdd 
appear  in  some  instances  that  the  unusual  precau- 
tion and  effort  at  concealment  showed  consciousness 
of  their  nature,  but  later  conduct  failed  to  confirm 
this. 

In  some  instances  strong  delusions  are  noted  to 
follow  large  doses  of  morphin.  In  some  cases  they 
disappear,  and  are  not  manifest  until  the  narcotism 
wears  away.  In  others  they  become  bold  and  show 
maniacal  impulses. 

A  physician  addicted  to  morphin  displayed  great 
harshness  to  his  patients  and  family  at  times; 
then  he  would  recognize  this  condition  and  be  very 
penitent  for  his  conduct.  On  one  occasion  he  drove 
his  wife  away  from  the  house,  and  two  hours  later 
went  after  her,  showing  great  tenderness.  This  was 
not  the  mania  seen  in  alcoholics,  but  a  calm,  reason- 
ing morbid  impulse  carried  out  deliberately  and  with 
every  appearance  of  sanity. 

In  a  case  to  which  the  author  was  called  in  con- 
sultation a  delusion  of  sudden  death  occurred  at 
stated  intervals.  The  patient  demanded  most  un- 
usual preparations  for  a  death-bed  scene.  Clergy- 
men were  called  and  a  large  family  gathered  to 
witness  his  exit.     Finally,  a  slight  interval  of  sleep 


Medicolegal  Study  of  Morphinomania     261 

Would  bring  a  change  and  the  desire  to  live  again 
returned.  This  was  not  hysteric,  but  a  calm,  reason- 
ing, hopeful  period  that  lasted  several  hours.  He 
gave  no  signs  of  mental  disturbance  nor  seemed  un- 
reasonable in  his  thoughts  or  conduct.  He  was 
known  as  a  user  of  morphin,  and  was  never  seen 
stupefied  by  its  results.  He  was  under  treatment 
for  its  removal  by  the  family  physician,  and  was 
secretly  using  it  when  these  trance  periods  arrived. 
He  had  only  a  faint  recollection  of  these  events 
afterward,  and  offered  foolish  explanations  that 
showed  that  he  did  not  realize  his  condition. 

In  another  case,  after  using  a  certain  amount  of 
morphin,  a  quiet,  unassuming  dentist  became  a 
strong  religionist.  He  would  march  with  the  Salva- 
tion Army,  and  make  eloquent  prayers  and  exhorta- 
tions. This  period  of  excitement  would  last  several 
days;  then  he  would  resume  his  former  quiet  life 
again.  In  the  religious  period  no  signs  of  mental 
failure  or  weakness  appeared.  He  seemed  in  every 
way  clear,  sensible,  and  earnest,  and  explained  his 
change  of  conduct  in  the  most  plausible  way. 

These  cases  illustrate  a  mental  state  which  occurs 
not  infrequently  among  morphinists  of  all  classes, 
and  particularly  in  persons  of  culture  and  more  than 
usual  mental  power.  The  confinement  of  such  persons 
for  a  few  weeks  and  the  removal  of  all  opportunities 
for  procuring  morphin  bring  out  the  real  condition. 


262  Morphinist 

This  closely  resembles  reasoning  mania,  except  in 
thef-'tralfnness  and  self-possession  manifested.  It 
would  seem  that  a  new  personality  is  involved,  and 
that  some  new  ideas  or  motives  take  full  possession 
of  the  mind,  and  all  other  conditions  and  surround- 
ings are  ignored. 

In  a  recent  murder  trial  a  morphinist  who  had 
evidently  been  associated  with  the  crime  in  some 
indirect  way  displayed  masterly  ability  in  the  ex- 
planation of  his  conduct.  He  shed  tears,  and 
created  a  strong  feeling  that  he  was  the  victim  of 
deception  by  others.  After  the  trial  the  facts  of 
his  complicity  came  out,  but  he  continued  indifferent 
and  utterly  ignored  them.  He,  no  doubt,  actually 
believed  his  own  statements,  and  unconsciously  used 
cunning  measures  to  make  them  appear  true. 

A  man  under  observation,  an  editor  of  ability,  has 
on  several  occasions  sent  out  startling  telephone 
messages  which  were  false.  Later  he  defended  his 
acts  with  unusual  plausibility,  and  it  was  ascer- 
tained that  he  was  a  secret  morphinist.  His  en- 
joyment was  probably  in  the  emotion  produced  by 
the  effects  of  such  news  on  others.  He  talked  freely 
of  these  false  statements  and  seemed  as  startled  as 
others  at  the  time.  He  is  now  under  medical  care, 
working  daily  at  home. 

There  are  no  theories  to  explain  this  condition 
other  than  some  obscure  palsy  of  certain  brain- 


Medicolegal  Study  of  Morphinomania     263 

centers  which  breaks  up  consciousness  of  right  and 
wrong,  or  suspends  reasoning  on  the  nature  and  con- 
sequences of  acts.  It  may  be  a  state  of  local  poison- 
ing which  centers  in  some  psychic  function,  giving 
prominence  to  some  idea,  which  is  defended  and 
explained  with  all  the  force  of  a  normal  brain. 
The  usual  efforts  to  explain  and  defend  acts  com- 
mitted under  the  influence  of  alcohol  are  often  so 
crude  as  to  carry  their  own  refutation.  The  mor- 
phinist in  this  state,  as  long  as  he  can  secure  a  suf- 
ficient amount  of  the  drug,  makes  fewer  mistakes 
and  shows  less  weakness  in  making  his  position  and 
conduct  appear  clear  and  sensible,  and  has  no  diffi- 
culty in  explaining  them  to  his  own  satisfaction.  It 
is  clear  from  this  that  in  certain  conditions  of  morphin 
addiction  a  new  personality  appears  whose  acts  are 
diametrically  opposed  to  those  of  the  person  in 
health  and  normal  condition. 

Hallucinations  and  delusions  accompanying  mor- 
phinism are  not  often  prominent,  and  mostly  concern 
trivial  matters ;  hence  are  seldom  investigated.  Occa- 
sionally they  come  into  legal  notice,  and  such  persons 
are  regarded  with  suspicion  as  being  guilty  of  maling- 
ering by  those  unacquainted  with  them.  Cases  like 
the  following  have  been  reported: 

A  prominent  woman  telephoned  the  police  station 
that  a  murder  had  been  committed  in  an  adjoining 
house.     The  officers  called  to  investigate  a  short 


264  Morphinism 

time  after  and  found  no  one  moving.  Two  servants 
were  working  before  an  open  window,  and  the  lady 
of  the  house  was  asleep.  The  accuser  described 
with  minuteness  of  detail  two  women  fighting  and  a 
man  rushing  in  and  stabbing  one,  then  disappearing. 
This  she  asserted  that  she  had  seen  from  her  window. 
The  basis  for  this  delusion  was  two  servants  working 
before  the  open  window  and  holding  up  the  gar- 
ments they  were  using.  She  was  told  that  it  was 
untrue,  and  became  very  angry  at  the  doubt. 
Later  she  was  found  to  be  a  morphin-taker,  suffering 
from  hallucinations  and  delusions. 

A  well-dressed  man,  with  a  bruised  face  and  some 
head  wounds,  appeared  at  the  police  station  and  gave 
minute  detail  of  an  assault  by  a  leading  merchant, 
who,  he  said,  had  attempted  to  kill  him.  The 
motive  was  supposed  to  be  political  and  to  prevent 
him  from  securing  a  nomination  which  another 
sought.  All  the  circumstances  of  the  assault,  with 
exchange  of  blows,  violent  language,  and  escape  by 
jumping  over  some  rocks  near  the  roadside,  were 
given  with  graphic  exactness.  In  reality  the  sup- 
posed assailant  proved  to  be  in  a  distant  city  at  the 
time,  and  could  not  possibly  have  been  the  person 
accused.  Other  circumstances  showed  that  no 
assault  had  taken  place,  and  that  the  accuser  was  a 
morphinist,  and  had  in  a  delusional  state  jimiped 
over  a  rocky  ledge,  injuring  himself. 


Medicolegal  Study  of  Morphinomania     265 

An  example  showing  the  magnitude  of  delusions 
following  the  use  of  morphin  was  a  subject  of  un- 
usual interest  and  inquiry.  A  widow  of  wealth  and 
culture  and  the  highest  respectability  charged  her 
physician,  a  man  of  high  character,  with  committing 
a  criminal  assault.  The  woman  was  supposed  to  be 
in  good  health  and  had  not  called  upon  her  physician 
professionally  for  years.  He  rarely  called  at  her 
house  except  on  some  mission  of  charity.  The 
offense  was  affirmed  to  have  been  committed  in  the 
early  part  of  the  evening,  and  the  woman  was  so 
shocked  that  she  remained  in  bed  for  two  days.  A 
week  later  she  confided  the  statement  to  her  clergy- 
man, and  a  lawyer  was  sent  for  and  a  meeting  held. 
The  woman  was  very  positive  in  her  statement,  and 
the  doctor  as  emphatic  in  his  denial.  It  appeared 
that  he  had  called  that  evening  about  seven  o'clock, 
remaining  only  a  short  time.  He  came  to  inform 
the  lady  of  the  death  of  a  relative,  who,  with  his  son, 
was  traveling  in  a  foreign  country.  After  leaving, 
the  doctor  accompanied  his  wife  to  the  theater,  and 
remained  home  during  that  night.  The  lady's 
statement  that  the  assault  was  committed  late  at 
night  was  changed,  and  it  was  asserted  to  have 
occurred  early  in  the  evening ;  and  when  pressed  for 
an  explanation  of  this,  she  seemed  confused  con- 
cerning the  exact  time.  The  very  unusual  feature 
was  the  apparent  tmimpeachable  integrity  of  both 


266  Morphinism 

parties.  There  had  been  only  a  feeling  of  respect 
between  them,  no  intimacy  nor  familiarity,  and  the 
physician  seldom  called  except  on  some  errand  of 
charity,  she  being  actively  engaged  in  the  manage- 
ment and  disposition  of  her  property.  The  matter 
was  referred  to  the  author.  The  only  suspicious 
circumstance  was  an  unusual  contraction  of  the 
pupils  and  excessive  paleness  and  nervous  uneasi- 
ness of  the  lady  who  made  the  accusation.  Dur- 
ing a  careful  inquiry,  she  acknowledged  that  she 
had  used  opium  in  the  form  of  McMunn's  Elixir 
at  different  times,  but  was  confident  that  it  was 
only  for  its  medicinal  effect,  and  that  it  had  no 
influence  other  than  to  produce  sleep.  An  inquiry 
at  a  neighboring  druggist's  brought  out  the  fact  that 
she  bought  large  quantities  of  morphin  continuously. 
The  matter  was  laid  aside,  awaiting  developments. 
Three  months  later  she  asserted  that  the  same 
physician  had  visited  her  room  at  midnight  and 
assaulted  her  as  before.  In  reality  the  physician 
was  on  the  ocean,  having  sailed  two  days  before 
the  act  was  alleged  to  have  been  committed. 
The  case  was  decided  to  be  an  opium  delusion. 
Soon  after  this  she  became  an  open  morphinist. 

Opium  is  not  often  used  in  this  country  for  crimi- 
nal purposes.  Its  effects  are  well  known  and  its 
detection  almost  certain,  hence  it  is  seldom  used 
except  by  novices.     In  India  and  southern  countries 


Medicolegal  Study  of  Morphinomania     267 

it  is  prominent  as  a  source  of  poisoning.  It  is  given 
with  the  food  or  drink  in  small  doses,  often  repeated, 
until  the  person  is  in  a  state  of  stupor  and  semi- 
unconsciousness  . 

In  some  instances  opium  is  given  to  foster  delu- 
sions in  the  mind  of  the  person  and  to  increase  his 
boldness  and  capacity  for  crime.  In  India  opium  is 
said  to  be  administered  with  hashisch  to  increase  the 
boldness  and  give  direction  to  the  delusions  which 
the  hemp  has  produced.  In  some  shops  these  drugs 
are  seen  together,  and  they  are  sold  for  the  purpose 
of  giving  energy  and  steadiness  to  purposes  and  plans 
of  mental  activity. 

The  reports  of  the  Indian  lunatic  asylums  mention 
ganja  or  hemp  as  a  very  prominent  cause  of  insanity. 
It  is  well  known  that  opium  is  nearly  always  asso- 
ciated with  it.  The  presence  of  the  insane  impulse 
called  " running  amuck"  has  been  traced  to  the  use 
of  hemp  and  opium,  and  is  sometimes  controlled  by 
the  latter  when  the  effects  of  the  former  have  passed 
away. 

In  Central  India  there  is  a  class  of  persons  who 
are  called  professional  druggers,  who,  for  pay,  ad- 
minister opium  and  other  drugs  to  make  the  person 
amenable  to  the  will  of  those  who  wish  to  use  him 
for  a  criminal  purpose.  The  opium  or  hashisch  is 
introduced  secretly  into  the  food  and  the  person  is 
either  robbed  or  persuaded  to  do  some  thing  desired. 
Manias  and  delirium  coming  on  suddenly  in  these 


268  Morphinism 

warm  countries  are  often  found  to  come  from  the 
use  of  opium. 

In  this  country  a  few  capital  cases  have  come  into 
prominence  where  opium  was  probably  used  for  a 
criminal  purpose.  But  unless  the  facts  are  carefully 
studied  and  unmistakable,  there  should  be  great 
doubt  of  its  special  responsibility. 

In  the  large  cities  persons  found  unconscious  after 
having  been  robbed,  are  not  infrequently  made  so 
by  the  use  of  opium.  But  it  is  seldom  used  by  crim- 
inals to  supply  personal  courage.  At  the  best,  it 
can  do  little  more  than  destroy  the  ethical  sense 
and  all  reasoning  as  to  the  consequences  of  the  act, 
and  where  crime  is  committed  by  a  criminal  who  is 
under  the  influence  of  opium,  it  often  lacks  the  ordi- 
nary sagacity  and  cunning  in  concealing  the  act  so 
common  in  other  persons.  It  is  also  clear  that  a 
person  under  the  influence  of  opium  has  less  vigor 
of  resistance.  If  attacked,  he  makes  a  very  feeble 
resistance  and  will  easily  succumb. 

Cases  of  opium-poisoning  for  criminal  purposes 
are  frequently  concealed  by  drowning.  Persons 
found  in  a  river  and  supposed  to  have  com- 
mitted suicide  or  accidentally  fallen  in,  are  un- 
doubtedly, in  many  instances,  stupefied  by  opium, 
assaulted  and  robbed,  and  then  thrown  into  the  river. 

The  following  are  examples  of  mental  conditions 
which  have  been  noted  in  certain  morphinists : 


Medicolegal  Study  of  Morphinomania     269 

A  judge  of  eminence  and  great  mental  ability  was 
noticed  to  show  mental  disturbances  at  times.  He 
would  appear  confused  and  express  himself  in 
exactly  opposite  statements,  then  adjourn  court  for 
a  few  moments,  and  upon  returning  exhibit  all  his 
former  acuteness.  His  general  appearance  showed 
neglect  and  carelessness,  and  his  manner  was  either 
impulsive  or  deliberate.  It  was  found  afterward 
that  he  used  morphin  by  the  needle.  Several  of 
his  decisions  were  reversed,  yet  he  showed  great 
acumen  in  defending  his  judgments  by  the  accumu- 
lation of  authorities  supporting  his  position.  In  a 
case  tried  before  him  in  which  the  mental  com- 
petency of  the  seller  of  a  piece  of  property  was 
questioned  from  the  fact  that  he  was  a  morphin- 
taker,  he  gave  a  very  strong  decision  support- 
ing the  claim  of  irresponsibility,  charging  the  jury 
that  morphinism  is  a  disease,  and  all  users  of  it 
incompetent  and  not  able  to  discriminate  in  mat- 
ters requiring  sound  judgment.  At  the  same 
time  he  was  himself  under  the  influence  of  the 
drug. 

A  similar  case  was  that  of  an  expert  physician 
who  swore  positively  to  the  insanity  of  a  criminal 
who  had  committed  crime,  acting  under  the  influence 
of  morphin  and  alcohol,  and,  while  he  was  himself 
imder  the  influence  of  the  drug,  sustained  a  very 
minute  examination  by  the  opposing  counsel. 


CHAPTER  X 
COCAINISM:   ITS  ETIOLOGY  AND   TREATMENT 

First  Described  as  a  Disease.  Theories  of  the  Value  of  Cocain. 
Cheapening  the  Cost  of  Production.  Use  by  the  Needle.  Exten 
of  Its  Use.  Where  Sold.  Two  Classes  Suffer  from  Its  Use  More 
Than  Others.  Early  Causes  of  Cocain  Habit  in  Previous  Spirit 
and  Drug  Addiction.  Different  Reasons  for  the  Use  of  Cocain. 
Two  Forms  of  Cocainism..  Some  General  Symptoms.  Delu- 
sions of  Strength  and  Vigor.  Later  Symptoms.  Comparison 
with  Morphinism.  Pathology  and  Injurious  Effects.  Treat- 
ment and  Legal  Care  Necessary. 

It  has  been  known  for  a  long  time  to  the  natives 
of  many  of  the  South  American  States  that  the 
leaves  of  the  Erythroxylon  Coca  plant  contain  some 
invigorating  principle  which  overcomes  fatigue  and 
increases  the  power  of  endurance,  but  the  fact  that 
the  alkaloid  of  this  plant,  cocain,  is  one  of  the  most 
subtle  and  dangerous  intoxicants  is  practically  new 
to  medical  science. 

The  general  physiologic  action  of  this  drug  as  a 

local  anesthetic  was  first  described  in   1866;  but 

twenty  years  afterward  Erlenmeyer  gave  the  history 

of  many  cases  of  cocainism,  and  pointed  out  this 

disease  for  the  first  time.     Many  quite  eminent  men 

denied  that  cocainism  was  a  distinct  disease  and  an 
/"■ 
addiction.     They  explained  the  intoxicating  symp- 

270 


Cocainism — Etiology  and  Treatment      271 

toms  as  due  to  other  drugs  and  conditions  of  the 
body.  One  physician  asserted  that  he  had  used 
cocain  in  large  doses,  personally  and  in  his  practice, 
without  any  poison  symptoms.  Another  claimed 
that  there  was  no  danger  from  its  use  unless  compli- 
cated with  other  drugs.  A  third  physician  and 
author  urged  that  it  be  given  as  a  tonic  for  muscular 
and  mental  fatigue  and  exhaustion,  and  cited  cases 
to  sustain  this  counsel.  Two  of  these  physicians 
died  from  diseases  directly  following  the  use  of  co- 
cain. 

The  cheapening  of  this  drug  has  greatly  increased 
its  use  and  popularity  in  prescriptions  where  pain 
and  irritation  are  to  be  overcome.  Used  by  the 
needle  for  local  anesthesia,  it  has  become  prominent 
by  the  absence  of  unpleasant  after-symptoms,  and 
the  conviction  of  its  safety  has  increased.  When- 
ever it  has  become  an  addiction,  the  victim  is  always 
possessed  with  the  idea  that  there  is  a  moderate, 
safe  use  of  the  drug,  which  it  is  possible  to  attain. 

There  are  many  reasons  for  believing  that  the 
strictly  medicinal  use  of  cocain  has  not  increased 
very  rapidly,  owing  to  its  variable  effects.  Den- 
tists, and  throat,  nose,  and  eye  specialists,  also  sur- 
geons, use  it  most  freely.  It  enters  very  largely  into 
many  popular  prescriptions  and  proprietary  com- 
binations of  drugs,  but  there  are  no  reliable  statis- 
tics which  indicate  the  extent  of  its  use. 


272  Morphinism 

The  custom-house  reports  indicate  an  enormous 
increase  in  the  importations  of  cocain  every  year, 
and  while  the  price  is  faUing,  the  demand  is  greater 
and  increasing  quantities  are  sold.  Inquiries  in 
the  large  cities  show  that  only  a  small  percentage 
of  cocain  is  consumed  legitimately.  In  Philadel- 
phia less  than  4  per  cent,  of  the  cocain  sold  went  to 
physicians,  dentists,  specialists,  and  hospitals.  In 
New  York,  Boston,  Chicago,  St.  Louis,  and  other 
cities  from  3  to  8  per  cent,  only  could  be  accounted 
for  in  legitimate  ways. 

As  there  are  no  restrictions  or  laws  regulating  its 
sale  in  most  towns  and  cities,  it  is  difficult  to  trace 
its  final  consumption.  Statistics  of  drug-store 
sales  bring  out  many  ctuious  facts.  Thus,  in  the 
lowest  sections  of  the  cities  cocain  is  in  great  demand 
in  both  drug  and  grocery  stores.  Tramp  peddlers 
carry  cocain  and  morphin  to  sell.  Cocain  is  sold 
openly,  and  is  eagerly  sought  for  the  quiet,  dreamy 
satisfaction  which  it  brings,  which  makes  it  very 
fascinating.  When  the  pauper  classes  are  unable  to 
procure  the  drug  honestly,  they  become  thieves  to 
secure  the  means  to  buy  it.  When  in  jail  and  de- 
prived of  the  drug,  they  become  delirious  and  are 
difficult  to  manage.  Usually  they  are  delusionally 
excited,  not  combative,  but  full  of  delirious  exalta- 
tion, with  dread  of  injury  and  siiffering,  and  are 
very  talkative  and  boisterous  in  manner. 


Cocainism — Etiology  and  Treatment      273 

The  drug-stores  in  the  wealthy  sections  sell  large 
quantities  of  cocain,  both  with  and  without  pre- 
scription. Formulas  containing  cocain  in  large 
amounts  are  popular,  and  in  great  demand.  The 
preparations  most  commonly  sold  are  called  "cold" 
and  "catarrhal"  remedies,  which  are  practically 
nothing  but  cocain. 

In  a  Connecticut  village,  where  many  of  the  people 
worked  in  a  dusty  factory,  a  physician's  prescription 
of  cocain  for  catarrh  became  very  popular.  At  one 
time  over  a  hundred  people  were  using  it.  Then  its 
contents  became  known,  and  its  sale  was  restricted, 
but  at  least  Jhree  of  these  persons  became  addicted 
to  its  use. 

Cocainism  seems  limited  to  persons  in  early  and 
middle  life,  and  is  most  commonly  seen  among  neu- r> 
rotics  and  brainworkers.  To  the  sensitive,  highly  de- 
veloped organization  cocain  brings  most  soothing 
relief.  To  the  stupid,  dull,  imbecile  brain  it  is  a  rev- 
elation of  comfort  and  rest  that  is  very  fascinating. 
To  the  worn-out  and  nerve-exhausted  man  it  gives  a 
temporary  fictitious  strength  and  vigor  which  are 
impressive.  To  the  sufferer  and  careworn  it  brings 
calm  and  peace.  Cocainism  is  a  new  disease  of  civili- 
zation, falling  most  heavily  on  the  extremes  of  society 
— the  wealthy  and  the  pauper  classes ;  and  also  on 
the  highly  intellectual,  also  the  dull  and  stupid  people. 

Probably  the  greater  number  of  persons  who  use 
18 


274  Morphinism 

this  drug  have  previously  taken  alcohol,  or  some  form 
of  opium  or  other  drugs.  From  the  effects  of  these 
drugs  general  disturbances  and  derangements  of  the 
body  follow,  and  cocain  is  used  with  most  pleasing 
results  for  a  short  time.  The  morphinist  finds  cocain 
a  perfect  substitute  for  the  depression  which  fol- 
lows the  use  of  the  opium  drug.  The  alcoholist  is 
charmed  with  the  relief  which  comes  from  cocain  and 
the  new  sensations  and  feeling  of  rest  which  it  brings. 
For  a  time,  cocain  is  taken  alternately  with  spirits 
and  other  drugs .  When  its  effects  are  unpleasant ,  it  is 
abandoned  for  some  other  narcotic .  In  this  way  many 
cocainists  are  heroic  drug-takers,  using  first  one  and 
then  another,  and  always  exhibiting  a  great  variety  of 
most  complex  mental  and  physical  symptoms. 

A  second  smaller  class  begin  the  use  of  cocain  for 
the  relief  of  pain,  irritation,  and  discomfort.  Its 
effects  are  so  pleasant  that  they  never  abandon  it. 
Catarrhal  states  are  checked  by  the  local  anesthesia 
which  it  produces.  Snuffing  the  powder  and  solu- 
tions is  a  very  common  way  of  using  it. 

Local  neuralgias  are  checked  at  once  by  needle- 
injections  of  a  solution  of  the  drug.  This  is  con- 
tinued, and  it  is  then  taken  for  other  disturbances  of 
like  character.  States  of  exhaustion  and  intense 
depression  are  temporarily  overcome  by  solutions  of 
cocain.  Insomnia  s^,nd  anxiety  pass  away  as  a  re- 
sult of  the  anesthetic  action  of  this  drug. 


Cocainlstn — Etiology  and  Treatment      275 

Cocainism  has  followed  from  its  first  use  for 
catarrh,  for  gastritis,  and  for  all  forms  of  local  and 
general  neuralgia.  It  has  been  given  for  its  anesthe- 
tic effects  in  injuries  and  operations,  and  used  ever 
after.  Physicians  have  used  it  personally  for  states 
of  exhaustion  and  anemia,  and  contracted  the  addic- 
tion. In  brief,  almost  every  condition  of  pain,  irrita- 
tion, exhaustion,  and  discomfort  has  been  the  start- 
ing-point of  cocainism. 

A  few  persons  have  become  addicted  through  the 
first  use  of  cocain  as  a  mere  experiment  to  test  its 
effects.  The  pleasing  action  made  so  profound  an 
impression  that  it  could  not  be  given  up.  Neurotics 
and  psychopaths,  both  from  inheritance  and  by 
neglect  of  the  laws  of  life  and  health,  are  common 
victims .  After  them  come  the  worn-out ,  t he  crowded- 
out,  and  the  nerve-  and  brain-disturbed  victims  of 
modem  life. 

Cocainism  appears  in  two  forms :  One,  the  periodic ; 
the  other,  the  continuous. 

The  periodic  form  is  marked  by  distinct  free 
intervals  in  which  all  desire  for  the  drug  is  lost. 
Then  a  state  of  unrest  and  physical  and  psychic  pain 
comes  on,  and  cocain  is  used  again  for  several  days 
or  weeks,  and  then  abandoned. 

In  the  free  interval  the  mental  impression  of  the 
pleasing  effects  of  the  drug  continues,  and  is  seldom 
overcome  by  fears  of  its  danger.     The  person  will 


276  Morphinism 

assert  that  he  will  never  use  it  again,  but  when  the 
paroxysm  returns  will  reason  that  there  is  little  risk 
or  danger  in  using  it  for  present  relief.  Many  of 
these  periodic  cases  suffer  from  neurotic  nerve- 
storms  which  precede  the  use  of  cocain. 

In  one  case  an  attack  of  asthma,  in  another  pain- 
ful insomnia,  in  a  third  disturbances  of  the  stomach 
and  palpitation  of  the  heart,  preceded  the  use  of 
cocain.  The  menstrual  period  in  women,  and  diges- 
tive headaches  in  men,  are  also  common  early  con- 
ditions. 

The  continuous  use  of  cocain  is  seen  in  neurotics 
and  exhausted  persons,  who  frequently  conceal  its 
use  and  show  great  ingenuity  in  explaining  any 
unusual  conduct  which  may  follow  indulgences  as 
due  to  other  than  the  real  cause.  After  a  time  nearly 
all  cocain-takers  become  continuous  users  of  the 
drug;  then,  in  the  efforts  to  conceal  its  effects,  other 
narcotics  are  employed.  In  this  way  morphin, 
spirits,  chloral,  and  many  other  drugs  are  taken,  and 
the  symptoms  become  complex  and  confusing. 

All  these  cases  are  cocainists  who  take  the  drug 
when  they  can  get  it,  and  substitute  some  other 
drug  if  it  is  difficult  to  obtain.  They  want  relief 
from  some  source,  and  any  drug  will  answer  their 
purpose  which  quiets  the  nervous  system. 

Cocainomaniacs  are  different:  they  become  liter- 
ally crazy  until  they  can  procure  this  drug.     Nothing 


Cocainism — Etiology  and  Treatment     277 

will  take  its  place.  They  siiffer  from  an  irresistible 
impulse  for  it,  and  their  minds  are  filled  with  delirious 
thoughts  of  the  pleasing  effects  which  will  ensue  from 
its  use. 

In  the  examination  of  a  delirious  lunatic  who  re- 
quired three  men  to  restrain  him,  he  whispered: 
"Get  me  five  grains  of  cocain  and  I  am  sane."  It 
was  given  him,  and  all  the  wild  delirium  subsided. 
He  was  transformed  into  a  quiet,  self-possessed  man. 
He  went  to  the  asylum,  and  there  was  some  doubt  of 
his  insanity  by  those  who  did  not  know  his  real  con- 
dition. 

The  action  of  the  cocain  is  to  raise  the  rapidity  of 
the  heart,  and,  in  large  doses,  the  respiration.  In  a 
poisonous  dose  the  temperature  is  raised,  and,  after 
a  period  of  excitement,  collapse  follows.  The  prin- 
cipal action  is  that  of  exhilaration  and  a  feeling  of 
increased  mental  and  muscular  strength.  The  brain  is 
stimulated  and  the  sense  of  physical  and  mental  well- 
being  exaggerated.     Pain  and  discomfort  disappear. 

When  given  by  the  needle,  the  nerves  in  the  vicin- 
ity are  anesthetized  and  all  sense  of  local  pain  disap- 
pears. Its  local  paralyzing  action  is  always  marked, 
and  in  some  instances  this  paralysis  extends  to  all 
parts  of  the  body,  with  a  feeling  of  comfort. 

A  pecuHar  increase  of  brain-activity  is  a  char- 
acteristic of  cocainism.  In  this  exaltation  the  pa- 
tient soon  develops  delusions  of  superior  strength 


278  Morphinism 

and  vigor,  and  perfect  command  of  himself.  Later, 
hallucinations  of  voices  appear,  and  then  delusions  of 
persecution  and  fears  of  personal  injury  fill  the  mind. 

The  cocainist  in  the  early  stages  is  always  self- 
possessed,  serene,  and  buoyant.  Nothing  disturbs 
him.  He  is  very  active,  talks  freely,  and  enjoys 
everything.  Later,  when  the  drug  wears  off,  he  be- 
comes morose,  excitable,  and  suspicious;  cannot 
sleep  at  night,  and  worries  at  the  prospect  of  trouble 
and  danger.  When  the  drug  is  taken  again,  the 
former  good  feeling  returns.  If  he  is  a  professional 
or  business  man,  occasions  for  the  return  of  the  stim- 
ulation increase ;  and  soon  cocain  is  taken  regularly, 
whenever  reactionary  symptoms  come  on. 

Finally,  intoxication  stages  appear,  in  which 
marked  volubility  and  prolixity  are  common  mani- 
festations. The  sense  of  good  feeling  creates  an 
intense  desire  to  talk  about  anything,  without  any 
definite  purpose  or  object.  If  the  cocainist  is  a  law- 
yer, clergyman,  political  speaker,  or  lecturer,  and  the 
drug  is  taken  immediately  before  appearing  in  pub- 
lic, great  volubility  will  result.  His  thoughts  will 
flow  on  in  a  continuous  current.  There  will  be  no 
pauses  and  no  dividing-lines,  but  one  steady,  con- 
nected flow  of  words,  involved,  and  without  point, 
direction,  or  end. 

A  noted  clergyman,  with  a  good  voice,  incurred 
the  displeasure  of  his  people  by  the  length  and  pro- 


Cocainism — Etiology  and  Treatment      279 

lixity  of  his  sermons.  Later  he  was  found  to  be  a  co- 
cainist.  An  eminent  medical  lecturer  would  suddenly 
become  oblivious  of  time  and  place  in  his  lectures. 
He  would  widen,  his  topic  to  such  an  extent  as  to  be 
lost  in  its  details,  talking  on  without  point  or  purpose, 
and  never  coming  to  a  logical  conclusion.  He  was  a 
cocain-user,  and  this  was  an  unmistakable  symptom. 
A  lawyer's  plea  before  a  jury  in  a  recent  trial  bore 
the  same  marks. 

Many  political  speeches  and  newspaper  articles 
bring  out  this  special  form  of  prolixity  and  diffuse- 
ness.  This  differs  widely  from  the  broken,  jarring 
sentences  of  alcoholists,  morphinists,  and  other  men- 
tal defectives.  The  style  of  the  cocainist  is  a  smooth, 
continuous,  involved  flow  of  words,  leading  in  no 
direction  and  almost  never  ending.  This  delusionary 
state  may  be  protracted  for  a  long  time,  and  can  be 
seen  in  works  of  fiction,  in  poetry,  and  even  in  med- 
ical journals. 

A  common  manifestation  of  this  condition  is  in 
letter-writing.  A  cocainist  will  think  to  convey  to 
some  one  an  abstract  truth  or  belief,  and  after  the 
first  sentence  or  paragraph  the  original  purpose  of 
the  letter  is  forgotten.  A  cocainist  wrote  from  four 
to  ten  letters  a  day  to  his  wife  about  the  care  of  his 
library  and  office.  The  closing  of  each  letter  sug- 
gested some  new  phase  of  the  subject  not  written  of 
before;  and  so  it  went  on. 


28o  Morphinism 

A  cocainist  who  proposed  to  come  under  my  care 
wrote  me  weekly  for  several  months,  from  four  to  six 
letters,  containing  opinions,  reflections,  and  sugges- 
tions covering  nearly  all  topics  of  history,  social 
science,  and  life  generally. 

In  some  instances  this  mania  for  letter-writing  has 
taken  on  a  slanderous  aspect,  but,  curiously,  the  ab- 
sence of  bitter,  sharp  words  and  distinct  charges  in- 
dicate the  cocain  origin.  Such  letters  usually  con- 
tain slanders  so  involved  and  mixed  that  their 
meaning  is  only  known  by  inference. 

Amatory  letters  in  the  same  diffuse  style  are  com- 
mon. Many  letters  in  famous  divorce  trials  show 
cocain-taking.  The  vagueness  and  obsctirity  of  the 
word-grouping  indicate  this  origin.  This  form  of 
exaltation  has  been  considered  symptomatic  of 
paresis. 

A  noted  man  was  placed  in  an  asylum  as  a  paretic. 
After  a  delusional  mania,  with  much  exhaustion,  he 
recovered.  His  mental  state  was  due  to  cocain, 
which  was  not  discovered  at  the  time. 

This  first  stage  of  mental  exaltation  is  after  a  time 
followed  by  hallucinations  of  sight  and  hearing. 
Insomnia  will  come  on,  with  muscular  agitation 
and  restlessness.  Suspicious  characters  will  appear 
watching  him,  and  voices  will  be  heard  plotting  to  do 
him  some  injury.  Then  he  will  begin  to  take  un- 
usual precautions — buy  revolvers  and  knives,  and 


Cocainism — Etiology  and  Treatment     281 

have  them  ready  for  defense.  Nearly  all  the  cocain- 
ists  the  author  has  seen  carried  revolvers,  and  ex- 
plained that  attempts  had  been  or  would  be  made  on 
their  lives;  so  they  were  justified  in  preparing  for 
them.  When  they  reach  this  stage,  other  drugs 
are  taken,  generally  morphin  and  spirits,  and  the 
cocainism  is  concealed. 

The  mental  exaltation  in  the  last  stages  is  very 
brief,  and  long  periods  of  restlessness  and  stupor 
follow,  with  disturbed  mental  stages  that  are  very 
apparent. 

The  diagnosis  of  these  cases  is  often  very  difficult. 
In  a  suspected  case  sometimes  the  only  change 
noticed  is  an  increased  desire  for  mental  and  in- 
tellectual work,  with  an  unusual  satisfaction  in  all 
the  conditions  of  life.  Close  study  will  show  a 
falling-off  in  the  character  of  the  work  and  the  de- 
gree of  judgment  displayed. 

If  a  physician,  defects  of  judgment  and  diminished 
recognition  of  ethical  duties  appear.  If  a  clerygman 
or  lawyer,  his  sense  of  the  propriety  and  the  right 
relation  of  things  siiffers.  His  work  is  less  exact. 
If  an  active  business  man,  his  former  caution  and 
candor  are  less  prominent. 

Thus,  in  many  ways  there  are  mental  changes, 
diminished  capacities,  and  slight  failures  of  the 
higher  brain-relations.  A  careful  study  of  the  symp- 
toms will  show  a  disappearance  of  the  buoyancy  at 


282  Morphinism 

short  intervals,  and  a  disposition  to  go  off  alone  for  a 
time,  with  a  return  of  self-confidence  and  elation. 
The  cocainist  differs  from  the  alcoholist  by  his 
solitary  habits,  and  from  the  morphinist  by  delusions 
of  persecution  in  the  later  stages. 

Later,  when  insomnia  with  extreme  nervousness 
comes  on,  unless  morphin  or  other  narcotics  are  taken 
to  conceal  the  symptoms,  the  diagnosis  can  be  made 
by  exclusion.  General  elation  and  solitary  habits,  with 
great  buoyancy  of  spirits,  are  significant  symptoms. 

When  cocain  is  used  to  lessen  the  pain  and  dis- 
turbance caused  by  spirits  or  opium,  the  peculiar 
mental  symptoms  of  cocainism  are  wanting,  and  rest- 
lessness with  insomnia  follows.  If  cocain  is  the 
leading  drug  taken,  short  exalted  periods  occur  with 
distinct  delusions  of  persecution.  The  latter  symp- 
tom is  present  in  nearly  all  cases,  whether  cocain  has 
been  the  primary  or  secondary  drug  taken. 

The  feeling  of  bugs  crawling  over  the  skin  comes 
in  the  later  stages,  and  is  a  very  significant  symp- 
tom. The  appetite  fails  and  anemia  appears,  par- 
ticularly when  other  drugs  or  spirits  are  taken  alter- 
nately. The  disposition  to  follow  any  consecutive 
work  grows  less  and  less  with  the  continuous  drug- 
taking.  With  these  come  a  general  failure  of  ambi- 
tion and  will-power,  and  reckless,  aimless  thought 

No  other  narcotic  known  up  to  this  time  makes 


Cocainism — Etiology  and  Treatment      283 

such  a  pleasing  physiologic,  impression  on  the  brain. 
The  new  world  of  strength  and  physical  happiness 
which  it  opens  to  the  victim  is  never  effaced  by  any 
ensuing  pain  and  suffering.  The  patient  has  gone 
into  a  new  land  and  experienced  the  bliss  of  perfect 
peace  with  the  world,  with  complete  command  of  his 
brain  and  enjoyment  of  active  work.  Ever  after, 
when  in  trouble  or  suffering,  the  memory  of  this 
comes  back,  and  with  it  the  desire  to  live  over  again 
the  experience  and  pleasure  which  it  brought. 

In  morphinism,  the  rest  and  oblivion  which  the 
drug  brings  seem  tooffer  escape  from  present  trouble. 
In  cocainism,  the  bHssful  satisfaction  which  comes 
from  this  drug  is  a  foretaste  of  an  ideal  life.  Hence 
the  difficulty  of  overcoming  this  impression  through 
any  profound  temporary  aversion,  growing  out  of  the 
suffering  and  pain  from  the  reaction  of  the  drug. 
The  cocainist  will  deplore  his  condition  and  make 
apparently  every  effort  to  overcome  the  diseased 
impulse,  and  yet  relapse  under  any  circumstances, 
though  he  may  see  clearly  the  peril  of  his  condition. 

If  cocain  is  taken  after  alcohol  or  opium  inebriety 
has  begun,  the  impression  is  less  vivid;  the  physio- 
logic action  is  more  anesthetic  and  less  stimulating. 
In  fatigue,  in  distress  and  suffering,  the  rapid  and 
complete  change  following  from  the  effects  of  cocain 
is  never  forgotten. 

When  morphin  or  spirits  are  taken  after  the  cocain 


284  Morphinism   . 

addiction,  the  injury  to  the  brain-centers  is  intensi- 
fied, and  both  mania  and  dementia  follow.  Com- 
plete insanities  of  all  forms  appear.  The  prognosis 
of  these  cases  is  always  grave.  While  recovery  does 
sometimes  take  place,  it  is  only  from  long,  insistent 
care  and  treatment.  Cases  complicated  with  alcohol 
and  opium  are  restored,  but  the  danger  of  relapse  is 
always  very  great. 

The  higher  sensory  neurons  have  Jbecome  perma- 
nently altered,  and  the  power  of  control  is  lost ;  the 
sense-centers  are  damaged  and  broken  up.  Sight, 
hearing,  taste,  smell,  and  sensation  are  seriously 
impaired.  The  removal  of  cocain  is  called  for  at 
once.  Substitutes  may  be  used  to  lessen  the  irrita- 
tion and  withdrawal  symptoms.  These  should  be 
vegetable  narcotics,  of  which  valerian,  hyoscyamus, 
and  others  of  this  class  are  useful.  The  bromids  are 
often  valuable  in  large  doses  for  a  brief  time.  Chlo- 
ral, alcoholics,  and  opium  are  unsafe.  The  insomnia 
must  be  treated  largely  by  foods  and  baths,  and  the 
various  functional  disturbances  of  the  body  by  ap- 
propriate remedies  as  called  for  in  each  case. 

The  conditions  are  largely  starvation  and  cell- 
poisoning,  and  absolute  change  of  surroundings 
and  conditions  of  living  is  essential.  The  patient 
should  be  sent  to  an  asylum  and  be  kept  under  the 
care  of  a  specialist  until  the  acute  symptoms  pass 
away.     Then  the  care  of  the  family  physician  for  a 


Cocainism — Etiology  and  Treatment      285 

long  time  is  necessary,  and  the  patient  must  follow 
exact  lines  of  hygienic  and  medical  direction. 

The  gravity  of  the  case,  and  its  recognition  by  both 
the  physician  and  patient,  should  be  fully  under- 
stood. All  conditions  which  provoked  the  first  use 
of  cocain  should  be  avoided.  The  giving-up  of  the 
drug  is  only  a  small  part  of  the  treatment,  A  study 
of  the  causes  and  conditions  which  led  up  to  its  use, 
and  their  prevention  and  removal,  are  the  central 
objects  of  correct  treatment. 

In  cocainism  the  patient  does  not  always  co-oper- 
ate with  the  physician,  but,  through  fear  and  pride, 
conceals  his  real  condition.  Often  the  treatment 
must  be  based  on  close  observation  and  inductive 
reasoning.  The  mind  and  body  are  seriously  im- 
paired and  require  joint  treatment.  This  treatment 
must  follow  well-recognized  principles,  and  be  based 
on  the  condition  of  each  case  and  its  special  neces- 
sities. 

In  conclusion:  The  fatal  cases  where  cocain  is 
given  for  its  anesthetic  effects  are  widely  reported  in 
medical  literature,  but  cocainism,  one  of  the  most 
dangerous  of  drug  addictions,  has  attracted  little 
attention,  and  its  literature  is  very  brief  and  regarded, 
with  doubt  and  skepticism.  There  can  be  no  doubt 
that  cocainism  is  increasing.  A  variety  of  unmis- 
takable symptoms  sustains  this  assertion;  symp- 
toms seen  in  newspaper  literature,  in  stories,  novels. 


286  Morphinism 

medical  writings — strange  conduct,  eccentricities, 
mysterious  acts,  and  sudden  deaths. 

Its  indiscriminate  sale,  without  restrictions,  in  all 
drug-stores  is  one  cause.  Its  reckless  use  by  physi- 
cians, who  accept  the  theories  of  teachers  and  others 
without  practical  experience,  is  another  cause.  The 
wide-spread  credulity  of  its  harmlessness  in  all  cases 
within  certain  limits  is  another  active  cause.  Its 
safe,  legitimate  use  in  medicine  is  limited;  and  it 
should  be  given  with  great  caution,  and  always  con- 
cealed from  the  patient.  As  a  narcotic  or  substitute 
for  other  narcotics  it  is  an  exceedingly  dangerous 
drug.  The  law  should  restrict  its  sale  as  a  veritable 
poison,  and  its  continuous  use  should  be  recognized 
as  insanity,  demanding  prompt  interference  and 
control.  Its  use  in  proprietary  medicines  is  a  source 
of  peril  of  greater  magnitude  than  that  of  any  form 
of  opium. 

Finally,  cocainism  has  become  a  most  serious  drug 
addiction,  whose  victims  are  often  physicians  and 
professional  men  in  all  circles  of  life,  together 
with  the  neurotics  and  drug-degenerates.  There  is 
only  one  way  of  escape  for  these  poor  drug- victims ; 
♦that  is,  to  give  up  everything  and  make  a  supreme 
effort  for  recovery.  With  the  assistance  of  some 
trusted  physician,  in  changed  conditions  and  sur- 
roundings and  the  most  favorable  circumstances 
possible,  the  prospect  of  permanent  cure  and  restora- 
tion is  hopeful. 


CHAPTER  XI 
CHLORALISM:  ITS  ETIOLOGY  AND  TREATMENT 

CMoraltsm  Seen  in  Women.  Used  for  Insomnia.  Irregular 
Action  of  the  Heart  Follows.  Mistaken  for  Other  Diseases.  Per- 
sons Addicted. 

Chloralism  is  another  form  of  drug  addiction, 
which  has  appeared  more  frequently  among  women. 
As  in  many  other  forms  of  drug  disease,  some  pre- 
vious neurosis  and  special  predisposition  are  found 
to  precede  the  first  use  of  this  drug. 

While  chloral  may  be  given  medicinally  for  some 
time  without  causing  gastric  or  intestinal  derange- 
ment or  producing  any  particularly  lasting  effects 
that  are  notable,  yet  there  is  always  the  possibility 
of  the  cultivation  of  a  craving  for  its  use.  Some 
authors  believe  that  it  is  one  of  the  most  easily  con- 
tracted addictions,  from  the  fact  that  its  effects  are 
more  pleasing,  and  its  use  can  be  continued  in  small 
doses  for  a  long  time. 

The  sleep  that  it  produces  is  often  very  profound 
and  followed  by  no  unpleasant  sensations  on  awaken- 
ing, and  this  may  be  repeated  many  times  without 
much  disturbance.  Chloral  can  often  be  taken 
secretly  without  any  suspicion  of  its  use.     After  a 

287 


288  Morphinism 

time  an  irregular  action  of  the  heart  and  the  increase 
of  nervousness,  with  muscular  unsteadiness  and  dis- 
ordered digestion,  appear.  In  elderly  persons  a 
form  of  cardiac  asthma  has  been  noted,  with  a  ten- 
dency to  delirium. 

Among  the  symptoms  noted  in  chloralists  are 
tremors,  sensory  impairments,  feeble  mental  action, 
intestinal  disturbances,  vasomotor  troubles,  includ- 
ing rashes  and  skin  diseases;  dyspnea  with  precor- 
dial distress,  and  even  asphyxia,  are  recorded.  Some 
authors  have  pointed  out  pains  in  the  joints  as 
symptomatic.  These  obscure  symptoms,  with 
others,  finally  merge  into  low  muttering  delirivmi, 
ending  in  acute  inflammation  and  death. 

Several  cases  are  reported  of  delirium  tremens 
which  have  been  altogether  due  to  chloral.  The 
usual  trembling,  delusions  of  persecution,  and  hal- 
lucinations of  sight  and  of  loathsome,  repelling  ani- 
mals occur.  If  the  physician  called  to  treat  such  a 
case  should  use  alcohol  freely,  supposing  it  to  result 
from  the  withdrawal  of  spirits,  the  mistake  often 
would  be  fatal.  Some  observers  have  pointed  out  a 
peculiar  blueness  and  venous  congestion  of  the  ex- 
tremities, with  marked  listlessness  and  lack  of  energy, 
as  prominent  symptoms  of  this  addiction. 

Chloralism  so  far  seems  to  be  confined  to  the  more 
prosperous  classes  of  society,  and  occurs  in  highly 
organized  and  sensitive  persons.     Its  first  use  is 


Chloralism — Etiology  and  Treatment     289 

often  to  procure  sleep.  It  can  be  disguised  in  many- 
ways,  and  constitutes  the  bulk  of  many  compounds 
advertised  as  hypnotics.  Several  proprietary  drugs 
on  the  market  for  headaches,  insomnia,  and  other 
neurotic  affections,  contain  chloral,  and  a  number 
of  addictions  have  followed  their  use. 

It  has  been  used  in  doses  of  from  twenty  to  a  hun- 
dred grains  a  day,  showing  an  unusual  toleration  and 
immunity  to  its  common  effects.  Many  of  these  cases 
accustomed  to  use  large  doses  daily  wiU  be  attacked 
with  extreme  prostration  and  delirium,  ending 
fatally. 

Sudden  palsies,  with  vasomotor  disturbances, 
heart  weakness,  and  low  stages  of  delirium,  should 
suggest  chloralism,  particularly  where  other  drugs 
can  be  excluded.  As  in  other  drug  cases  where  ex- 
treme neuralgias,  insomnias,  and  painful  conditions 
rapidly  disappear  into  quiet,  dreamless  sleep,  the 
assumption  that  chloral  is  used  is  very  strong. 

In  criminal  circles  chloral  in  concentrated  form  is 
put  into  spirits  and  beers  to  narcotize  the  victim  for 
the  purpose  of  robbery.  Such  combinations  are 
called  "knock-out  drops,"  and  are  very  effectual  in 
quickly  narcotizing  one  already  under  the  influence 
of  spirits.  This  is  readily  explainable  from  the  fact 
that  chloral  is  composed  of  chlorin  and  alcohol,  hence 
alcoholics  would  naturally  be  more  susceptible  to 

its  effects. 
19 


290  Morphinism 

Ordinarily  chloralism  is  not  a  substitute  for  alco- 
holism, although  it  piay  follow  morphinism  for  a 
short  time ;  but  the  delirium  which  is  the  inevitable 
outcome  of  its  toxic  use  prevents  an  addiction  for 
any  length  of  time,  especially  when  associated  with 
spirits. 

When  the  fact  is  established  that  the  person  is 
addicted  to  chloral,  it  should  be  removed  at  once. 
First,  the  person  should  be  isolated  and  placed  in  a 
position  where  restraint  and  control  of  the  surround- 
ings can  be  obtained;  then  the  drug  withdrawn. 
Alcohol,  opium,  chloroform,  ether,  or  cocain  should 
never  be  used  in  the  treatment  as  substitutes.  Only 
vegetable  narcotics,  such  as  valerian,  lupulin,  asa- 
fetida,  bull  nettle,  and  others  of  this  class,  should  be 
given. 

The  usual  tonic  treatment  with  nux  vomica, 
strychnin,  and  arsenic  is  required.  The  latter  should 
be  used  for  a  long  time.  Mineral  waters  seem  to  be 
very  efficacious.  For  the  profound  exhaustion  and 
depression  which  follow,  cinchona,  iron,  and  the 
bitter  tonics  are  excellent.  Baths  and  massage 
should  be  taken  daily,  with  every  hygienic  measure 
found  essential. 

Many  chloral  addictions  have  been  mistaken  for 
paralysis  and  organic  affections  of  the  cord  and  brain. 
An  active  early  treatment  will  often  clear  away  some 
of  the  confusing  symptoms.    When  opium  and  alco- 


Chloralism — Etiology  and  Treatment      29 1 

liol  are  complicated  with  the  addiction,  the  recovery 
will  be  slower. 

The  withdrawal  symptoms  are  never  severe,  al- 
though sudden,  unexpected  death  from  various 
causes  may  occur  at  any  time.  All  such  cases  re- 
quire both  physical  and  mental  treatment,  and  the 
complexity  of  the  symptoms  and  general  derange- 
ment which  follow  are  usually  symptomatic,  and 
disappear  with  rest  and  quietness. 

The  mental  symptoms  are  not  very  pronounced,  • 
and  are  usually  of  a  low,  demented  type.  The  delu- 
sions concern  matters  of  food  and  drink  and  sur- 
roundings, and  rarely  extend  beyond  the  most  selfish 
range  of  thought.  Fear  of  dying  is  more  common 
than  fear  of  injury,  and  anticipated  disease  is  also 
a  frequent  dread. 

The  chloral-taker,  like  other  drug-users,  soon  be- 
comes anemic;  has  a  glassy  eye  and  shriveled  ap- 
pearance; eats  irregularly,  is  secretive,  avoids  pub- 
licity, goes  by  himself,  and  is  constantly  explaining 
his  condition  as  due  to  other  causes.  Early  in  the 
use  of  the  drug  motor  disturbances  appear,  with 
trembling  and  agitation  when  the  drug  is  withdrawn. 
The  mind  does  not  seem  to  be  seriously  affected  ex- 
cept in  the  effort  to  conceal  the  condition.  All  effort, 
both  mental  and  physical,  is  avoided.  The  chloral- 
taker  is  neither  able  nor  disposed  to  attempt  anything 
requiring  consecutive  thought. 


292  Morphinism 

Very  few  persons  of  this  class  acknowledge  their 
addiction,  and  even  when  under  treatment  are  de- 
luded with  the  idea  that  other  causes  are  more  active 
and  responsible.  All  such  cases  are  irresponsible, 
and  cannot  be  trusted  to  act  consistently  and  sanely 
on  matters  in  which  they  are  interested. 

The  sudden  death  of  an  inebriate  in  criminal  asso- 
ciation and  suspected  crime  should  suggest  the  use  of 
chloral.  Several  cases  have  been  reported  of  drink- 
ing men  dying  in  a  profound  stupor  suggesting 
chloral  narcotism. 

A  case  noted  in  the  daily  press  describes  what 
undoubtedly  occurs  more  frequently  than  is  sus- 
pected. The  victim  was  a  respectable  man  of 
wealth,  who  drank  periodically.  He  was  seen  par- 
tially intoxicated  in  a  low  saloon.  Two  hours  later 
he  was  found  dead  in  the  street.  He  had  been 
robbed,  and  after  drinking  beer  suddenly  became 
stupid  and  died.  In  another  case,  that  of  a  periodic 
beer-drinker  who  died  suddenly  of  profound  narcot- 
ism, death  was  evidently  caused  by  chloral,  although 
it  was  difficult  to  trace  its  use. 

Disreputable  drug-stores  have  always  a  large 
trade  in  chloral  and  other  narcotics.  Chloral  should 
always  be  suspected  as  the  cause  in  cases  of  sudden 
profound  stupor  and  death. 


CHAPTER  XII 

CHLOROFORMISM:  ITS   ETIOLOGY  AND 
TREATMENT 

More  Common.  Follows  from  Neurotic  States.  Used  for  Specific 
Pain.  After  the  Paroxysm  Repulsion  Follows.  Periodicity. 
Secrecy.  Tetanoid  Symptoms  Follow.  Treatment.  Change  of 
Surroundings  Required.     Prognosis.     Remedies  Useful. 

The  use  of  chloroform  for  its  narcotic  effects  is 
becoming  more  common,  and  already  a  number  of 
cases  have  been  reported  which  iryiicate  its  preva- 
lence in  many  circles.  Nearly  all  cases  seem  to 
follow  from  some  previous  narcotic  addiction.  Thus 
from  the  insomnia  and  wretchedness  which  follow 
the  withdrawal  symptoms  of  alcohol  or  opium  relief 
is  obtained  by  the  inhalation  of  chloroform.  Fre- 
quently chloroform  is  used  to  break  up  the  drink 
craze,  and  later  its  effects  are  so  pleasant  that  it 
takes  the  place  of  the  alcohol  or  opiimi. 

In  most  of  the  cases  reported  its  first  use  was  fpr 
some  acute  pain  or  distressing  condition  of  insomnia, 
or  some  peculiar  irritation  associated  with  exhaus- 
tion. The  relief  has  been  so  prompt  that  the  repeti- 
tion of  the  drug  was  demanded.  The  odor  is  also 
very  attractive,  and  for  many  persons  has  a  peculiar 

293 


294  Morphinism 

fascination.  This,  with  the  dreamy  oblivion  which 
follows,  creates  a  profound  impression  on  the  nerve- 
centers. 

In  all  cases  chloroform  is  first  used  for  some  specific 
purpose.  If  the  use  is  continued,  an  addiction  fol- 
lows. Often  this  is  periodic,  with  long,  uncertain 
free  intervals.  In  most  instances  it  is  used  at  night. 
In  the  later  stages  it  is  used  at  any  time,  and  is  fol- 
lowed by  degrees  of  mania  and  melancholia.  After 
a  prolonged  stupor  a  feeling  of  repulsion  follows, 
and  the  derangement  and  general  malaise  gradually 
wear  off  in  two  or  three  days. 

In  the  periodic  cases  the  stated  intervals  some- 
times occur  weeks  and  months  apart,  the  attack.- 
being  preceded  by  a  degree  of  hyperexcitability 
associated  with  insomnia  and  extreme  restlessness, 
impending  fears,  and  dread  of  some  serious  disaster. 
Drugs  will  be  repelled.  Morphin  and  spirits,  when 
taken,  seem  rather  to  increase  than  diminish  the 
suffering.  Finally  the  desire  will  come  on  to  have 
the  oblivion  of  chloroform  stupor.  A  quantity  will 
be  secured  and  the  conditions  arranged  for  the  in- 
halation. This  will  sometimes  extend  over  one  or 
two  days,  imtil  the  stomach  revolts  and  nausea  and 
vomiting  follow.  Then  the  nerve  symptoms  seem 
to  subside  and  a  great  effort  is  made  to  recover,  A 
long  free  interval  follows,  and  the  same  scene  will  be 
re-enacted. 


Chloroformism — Etiology;  Treatment    295 

The  intervals  growing  shorter,  sometimes  opium  is 
taken  to  lessen  the  abstinence  symptoms ;  then  the 
effort  to  abandon  this  drug  intensifies  the  desire  for 
the  chloroform  narcotism. 

In  one  instance  a  man  who  by  accident  had  found 
relief  from  the  inhalation  of  chloroform,  and  became 
addicted  to  its  use,  had  certain  stated  intervals  in 
which  chloroform  was  taken.  For  several  years 
these  intervals  were  exactly  four  months,  at  the  ter- 
mination of  which  he  would  retire  to  some  secluded 
place  and  inhale  one  or  more  pounds  of  chloroform ; 
then  recover  and  resume  his  business  again.  The 
interval  was  spent  in  careful  hygienic  living,  uniform 
work,  and  efforts  to  build  up  the  system  and  to  break 
up  this  paroxysm.  To  his  friends  and  physicians  he 
expressed  intense  anxiety  to  be  protected,  but  when 
the  time  approached  became  secretive,  and  provided 
by  arranging  his  business  so  that  nothing  would 
suffer  during  his  absence ;  then  gave  way  to  the  im- 
pulse, and  despite  all  efforts  could  not  be  restrained. 
These  attacks  continued  for  several  years,  until 
death  from  acute  inflammatory  conditions  ensued. 

Of  these  inflammatory  conditions,  neuritis  is  the 
most  common,  and  most  cases  end  from  tetanic 
paroxysms.  Sudden  death  from  syncope  is  also 
common. 

The  fascination  for  this  drug  becomes  an  insane 
impulse  which  possesses  both  mind  and  body  beyond 


296  Morphinism 

all  power  of  reason  and  control.  Often  it  bursts  out 
suddenly  without  premonition.  A  favorable  oppor- 
tunity to  procure  it  or  the  odor  of  the  drug  seems  to 
provoke  the  desire,  which  at  once  becomes  an  obses- 
sion. After  this  impulse  dies  out  the  efforts  for  re- 
covery are  equally  earnest  and  energetic.  While 
showing  great  anxiety  and  dread,  and  doing  all  that 
is  possible  to  prevent  relapse,  yet  the  slightest  oppor- 
timity  to  procure  the  drug  and  conceal  it  is  taken 
advantage  of.  The  impulse  is  so  overpowering  that 
although  it  may  be  concealed  for  the  time,  it  con- 
stantly seeks  the  means  and  opportimity  for  its 
gratification. 

There  is  in  this  a  pronounced  insanity,  with  an 
extreme  liability  to  take  on  most  tmexpected  types 
and  symptoms.  While  it  is  always  possible  to  over- 
come this  impulse  with  morphin  or  other  drugs,  yet 
the  fascination  from  the  memory  of  chloroform  nar- 
cotism is  never  effaced. 

Some  very  interesting  cases  of  the  mental  dis- 
orders following  the  use  of  chloroform  were  described 
by  Dr.  Savage  in  1898.  Since  that  time  a  number  of 
cases  have  been  reported,  some  of  them  becoming 
literal  chloroform  manias,  others  taking  various 
forms  of  mania  and  melancholia  with  complex  symp- 
toms. These  cases  were  largely  persons  who  after 
the  anesthesia  from  chloroform  for  some  specific 
ptirpose,  such  as  surgical  operation  or  pain  parox- 


Chloroformism — Etiology  ;  Treatment    297 

ysm,  became  maniacs.  The  stupor  from  chloroform 
developed  mental  excitement,  delirium,  and  delu- 
sions. 

One  of  these  instances  was  that  of  a  lady  who  used 
chloroform  daily  for  toothache,  and  continued 
maniacal  for  several  weeks.  A  second  example  was 
that  of  a  surgical  operation  on  the  rectum,  after 
which  the  man  remained  demented  for  a  long  time ; 
then  suddenly  recovered,  and  had  no  recollection  of 
what  had  happened  during  the  time  that  had  elapsed 
since  the  operation.  Cases  of  puerperal  insanity 
where  the  use  of  chloroform  dining  labor  was  fol- 
lowed by  deliriiun  are  recorded. 

A  case  still  more  remarkable  seemed  to  follow  the 
use  of  chloroform  for  paroxysmal  headache.  In  this 
instance  for  over  a  week  the  patient  was  partially 
demented,  not  knowing  where  he  was  and  having 
delusions  of  contentment,  laughing  and  smiling  at 
everything  that  occurred  about  him.  He  recovered, 
and  a  year  afterward  began  to  frequently  use  small 
quantities  of  chloroform  at  night.  The  next  day 
he  was  stupid  and  dull,  and  the  second  day  re- 
covered, and  appeared  well  until  another  attack. 

Evidently  these  cases  were  neurotics  with  a  pecu- 
liar nervous  idiosyncrasy  that  foimd  most  grateful 
relief  in  this  form  of  narcotic.  The  treatment  in  this 
form  of  drug-addiction  is  removal  of  the  drug  at  once 
and  change  of  stirroimdings  and  conditions  of  living. 


298  Morphinism 

Physical  exercise,  with  baths,  tonics,  and  attention 
to  diet,  are  the  therapeutic  measures  most  essential. 

When  the  person  is  not  accustomed  to  other  nar- 
cotics, this  craze  is  one  of  insane  impulse,  which, 
although  it  may  be  suppressed  by  morphin  or 
other  drugs,  persists  until  it  is  gratified.  Usually 
irritative  melancholy,  with  restlessness  and  strange 
half -imbecile  conduct,  indicates  the  presence  of  this 
impulse. 

In  one  instance  a  man  who  repeatedly  used  this 
drug,  and  always  appealed  to  his  physician  for  help 
when  the  paroxysm  was  over,  and  at  the  same  time 
intrigued  to  procure  it  again,  was  taken  to  a  hospital, 
given  morphin,  and  put  to  bed.  Two  hours  after- 
ward he  was  found  by  the  nurse  wandering  round 
trying  to  escape  by  the  window.  He  was  seized, 
dragged  to  a  shower-bath,  and  thoroughly  showered 
with  cold  water  and  rubbed,  then  put  to  bed.  The 
effect  was  charming ;  all  desire  for  narcotism  passed 
away.  A  week  later  the  same  means  were  tried  in 
his  own  house  with  success. 

Chloral  does  not  act  well ;  it  is  rather  an  excitant 
than  a  narcotic  in  such  cases,  and  the  stimulation 
which  comes  from  its  use  is  often  followed  by  greater 
depression.  Bromids  in  large  doses  have  been 
tried,  but  their  continued  use  is  injurious,  and  the 
depression  which  follows  is  marked  and  difficult 
to  overcome. 


Chloroformism — Etiology;  Treatment    299 

Opium  in  any  form  may  be  given,  but  should  be 
concealed.  There  is  danger  that  it  may  take  the 
place  of  chloroform ;  and  if  it  does  not  act  promptly, 
it  should  not  be  used.  In  all  instances  attention 
should  be  paid  to  the  nutrition  and  the  alimentary 
canal.  Mineral  cathartics  and  saHne  drinks  are 
very  valuable. 

Recovery  from  the  stupor  is  often  accelerated  by 
coffee  infusion,  salt  bathing,  and  mineral  acids. 
After  recovery,  arsenate  of  iron  or  the  iodid  of  potas- 
sium should  be  given  for  some  time. 

If  the  case  is  kept  imder  carefid  observation,  the 
premonitory  symptoms  of  the  approaching  paroxysm 
may  be  anticipated,  first,  by  vegetable  narcotics  and 
Turkish  baths ;  and  every  means  to  divert  the  mind 
and  rouse  a  new  set  of  thoughts  to  overcome  the  im- 
pulses should  be  employed. 

Often  active  catharsis  is  of  value,  indicating  that 
possibly  some  state  of  autointoxication  may  precede 
and  excite  the  chloroform  impulse.  In  some  in- 
stances active  exercise,  change  of  scenery,  and  every 
other  means  that  will  possibly  divert  the  functional 
activities  of  the  mind  and  body  should  be  employed. 

Often  with  the  increase  of  the  addiction  there  will 
be  associated  greater  ingenuity  and  cunning  to  cover 
up  the  impulse  and  secure  opporttmities  for  its  grati- 
fication. In  the  few  cases  noted,  active  heroic 
measures  have  impressed  the  organism  so  thoroughly 


300  Morphinism 

as  to  break  up  the  impulse  and  restore  the  mental 
equilibrium. 

The  use  of  alcohol  is  always  dangerous,  increasing 
the  degeneration  and  provoking  mental  symptoms 
which  are  significant  of,  nerve  change.  In  all  cases 
the  patient  should  be  under  the  constant  care  of  the 
attendant  and  physician,  and  every  dangerous  symp- 
tom should  be  watched  and  provided  against. 

When  chloroform  is  given  for  surgical  operation  or 
for  convulsive  pain,  and  is  not  followed  by  any  un- 
pleasant effects,  such  as  headache  and  nausea,  it 
should  be  considered  as  particularly  dangerous, 
through  the  liability  of  an  addiction,  and  should 
never  be  used  except  in  emergency. 

When  chloroformism  occurs  in  middle  or  later  life, 
the  prognosis  is  very  serious.  The  results  are  usually 
fatal  from  syncope  and  tetanoid  spasms.  When  it 
occurs  in  early  life,  the  prognosis  is  better.  In  all 
cases  there  are  serious  defects  of  both  mind  and  body, 
which  require  skilful  and  prolonged  treatment  in 
special  surroundings. 
y  ;  Some  years  ago  the  question  was  raised  in  the 
"^  criminal  courts  whether  chloroform  could  be  used 
for  criminal  ptirposes  without  the  knowledge  of  the 
person  on  whom  it  was  used.  In  the  discussion 
which  followed  many  very  curious  facts  appeared,  the 
final  conclusion  of  which  was  that  a  certain  very 
small  proportion  of  persons,  under  the  most  favora- 


Chloroformism — Etiology  ;  Treatment    301 

ble  and  exceptional  conditions,  might  be  narcotized 
by  chloroform  without  their  knowledge.  These  were 
only  exceptional  cases,  and  the  statement  that  per- 
sons had  been  put  to  sleep  by  this  drug  without  their 
knowledge  was  very  largely  mythical.  If  the  person 
was  under  the  influence  of  some  other  narcotic,  such 
as  alcohol  or  opiimi,  it  was  possible  to  deepen  the 
narcotism  into  a  profound  sleep  by  inhalation  of 
chloroform  given  with  circumspection  and  care.  In 
all  cases  it  was  found  that  the  effect  of  inhalation 
was  irritating  to  the  mucous  membrane,  and  pro- 
duced coughing  and  a  feeling  of  strangulation,  which 
in  most  cases  startled  the  consciousness  to  wakeful- 
ness. This  consciousness  of  the  situation  might  be 
very  brief,  but  in  most  instances  it  would  be  asso- 
ciated with  alarm,  and  the  patient  would  start  up  in 
resistance. 

In  a  prominent  case  where  the  man  came  home 
stupid  from  alcohol  a  cone  with  chloroform  vapor 
was  applied  to  his  mouth,  and  he  was  heard  to  cough 
and  mutter  as  if  in  resistance.  Two  hours  later  he 
was  found  dead.  The  odor  of  chloroform  pointed  to 
the  drug  used  to  produce  death.  In  another  instance 
a  drunken  man  was  awakened  at  the  effort  to  chloro- 
form him,  and  became  suddenly  delirious,  and  vio- 
lent to  those  about  him. 

There  are,  no  doubt,  persons  susceptible  to  the 


302  .  Morphinism 

narcotism  of  chloroform  who  after  only  a  brief  mo- 
ment of  excitement  are  overcome  by  its  influence. 

The  experience  of  large  hospitals  in  the  use  of 
chloroform  as  an  anesthetic  confirms  these  facts,  and 
shows  the  difficulties  of  producing  narcotism  against 
the  will  of  the  person.  In  all  probability  persons  in 
deep  sleep  would  be  awakened  by  the  first  inhalation 
of  chloroform  vapor,  and,  at  all  events,  it  would  re- 
quire extraordinary  care  and  persistence  on  the  part 
of  the  criminal  to  produce  sleep  from  this  drug.  The 
persistence  of  the  odor  in  the  room  and  on  the  breath 
and  in  the  clothes  of  the  person  would  afford  diag- 
nostic evidence  of  an  unmistakable  character. 
J  It  is  not  disputed  that  persons  may  be  held  and 
[  forcibly  made  to  inhale  the  chloroform,  and  in  this 
way  become  stupefied,  but  such  cases  are  rare,  and 
if  death  follows  it  will  be  from  heart  collapse. 
Several  medicolegal  questions  are  still  unsolved  in 
regard  to  the  use  of  chloroform  for  criminal  purposes. 
At  present  it  is  safe  to  assume  that  this  is  a  very  im- 
practicable drug  for  forcible  narcotism.      { 


CHAPTER  XIII 
COFFEE  ADDICTION 

Its  Peculiar  Symptoms.  Questions  of  Medicolegal  Interest  which 
Come  from  Such  Cases.  Associated  with  Other  Addictions.  Ef- 
fects on  Young  Persons. 

Coffee  addiction  is  of  the  same  class  of  neuroses, 
only  not  so  prominent.  The  widespread  use  of  coffee 
has  been  followed  by  extensive  adulteration,  which 
lessens  its  injurious  action  on  the  body.  Coffee- 
drinkers  or  those  who  use  it  to  great  excess  soon 
suffer  from  insomnia  and  nervousness,  and  when 
they  realize  the  cause,  abandon  it.  The  craze  for 
coffee  is  rarely  so  intense  and  never  so  long  continued 
as  that  for  other  drugs,  and  can  be  more  easily 
broken  up  by  substitutes. 

In  some  extreme  cases  delusional  states  of  a  gran- 
diose character  appear ;  rarely  violent  or  destructive, 
but  usually  of  a  reckless,  imthinking  variety.  As- 
sociated with  these  are  suspicions  of  wrong  and 
injustice  from  others;  also  extravagant  credulity 
and  skepticism. 

Some  very  curious  instances  of  coffee  intoxication 
have  been  reported.     One,  of  a  prominent  general 

303 


304  Morphinism 

in  a  noted  battle  in  the  Civil  War:  after  drinking 
several  cups  of  coffee  he  appeared  on  the  front  of  the 
line,  exposing  himself  with  great  recklessness,  shout- 
ing and  waving  his  hat  as  if  in  a  delirium,  giving 
orders  and  swearing  in  the  most  extraordinary  man- 
ner. He  was  supposed  to  be  intoxicated.  After- 
ward it  was  foimd  that  he  had  used  nothing  but 
coffee. 

On  another  occasion  a  prominent  political  orator 
astonished  his  audience  by  a  wild  harangue  of  ex- 
clamatory sentences,  ending  in  threats  and  predic- 
tions. Later  it  was  found  that  he  had  drunk  freely 
of  coffee  for  twenty-four  hours  or  more,  and  was 
suffering  from  a  veritable  coffee  delirium. 

Often  coffee  drinkers,  finding  the  drug  to  be  un- 
pleasant, turn  to  other  narcotics,  of  which  opium 
and  alcohol  are  most  common.  The  treatment  of 
these  cases  is  along  the  line  of  general  principles, 
elimination  by  baths,  with  catharsis,  nerve  and 
brain  rest. 

A  very  interesting  question  was  raised  in  a  dis- 
puted will  case  as  to  the  capacity  of  the  executor  of  a 
will  who  drank  coffee  in  large  quantities,  and  was  in 
an  excited  state  continuously.  It  was  shown  that 
he  had  mild  delusions,  believed  himself  possessed  of 
great  wealth,  assumed  that  his  disposition  of  prop- 
erty was  perfectly  clear,  and  would  not  permit 
alteration.     He  was  insomniac,  trembling,  and  de- 


Coffee  Addiction  305 

scribed  by  one  witness  as  having  delirium  tremens. 
The  will  was  put  aside  because  of  these  and  other  facts. 

There  can  be  no  question  that  both  tea  and  coffee 
habitues  are  impaired  in  mind  and  body,  and  their 
acts  and  conduct  may  in  certain  cases  be  open  to 
serious  question. 

A  recent  writer,  Dr.  Leszynsky,  has  called  atten- 
tion to  acute  and  chronic  caffeinism.  On  the  general 
subject  he  writes  as  follows: 

"I  have  seen  victims  of  the  coffee-habit  among 
commercial  travelers,  brokers,  merchants,  actors, 
writers,  and  men  connected  with  the  news  depart- 
ments of  the  daily  papers.  In  fact,  they  are  strik- 
ingly frequent  among  those  who  are  working  under 
high  pressure,  and  whose  occupation  requires  a 
great  deal  of  talking  or  mental  activity.  In  order 
to  produce  the  desired  stimulation,  they  find  it  neces- 
sary continually  to  increase  the  dosage,  just  like 
those  who  have  the  'alcohol  habit'  or  the  'opium 
habit.*  Their  general  health  becomes  impaired,  and 
the  functional  activity  of  every  organ  may  be  af- 
fected. They  usually  complain  of  the  following 
symptoms,  which  are  more  or  less  pronounced,  and 
in  varying  combination:  general  headache  and 
'  nervousness ' ;  apprehension  in  regard  to  some  un- 
known impending  trouble;  mental  depression  and 
irritability ;  insomnia  or  restless  sleep ; '  bad  dreams ' ; 
sudden  'starting'  in  sleep  and  awaking  in  profuse 


3o6  Morphinism 

perspiration ;  occasional  or  frequent  vertigo ;  general 
tremulousness  and  diminished  muscular  power; 
precordial  oppression;  cardiac  palpitation;  loss  of 
appetite;  frequent  eructation  of  gas,  and  constipa- 
tion. The  symptom-complex  most  commonly  noted 
is:  general  nervousness;  tremor;  vertigo;  restless 
sleep;  cardiac  palpitation;  eructation  of  gas;  and 
constipation.  On  examination  we  usually  find  a 
coated  and  tremulous  tongue ;  tremor  in  the  eyelids 
while  standing  with  closed  eyes ;  in  some  the  pupils 
are  slightly  dilated,  but  react  quickly  to  light ;  tre- 
mor in  both  outstretched  hands ;  rapid  pulse,  of  low 
tension  and  frequently  irregular,  ranging  from  90 
to  130;  exaggerated  reflexes,  and  more  or  less  in- 
creased reflex  irritability.  Tachycardia  or  brady- 
cardia may  also  be  present. 

"  It  must  be  seen  that  this  entire  series  of  neu- 
rasthenic symptoms  may  result  from  other  causes, 
such  as  the  excessive  use  of  alcohol,  tea,  or  cocoa,  or 
from  a  combination  of  several  factors.  As  a  general 
rule,  it  is  most  frequently  mistaken  for  chronic  alco- 
holic toxemia.  It  is  not  difficult  to  determine  by  a 
process  of  exclusion,  however,  that  the  condition  in 
question  is  beyond  any  doubt  attributable  to  exces- 
sive coffee  drinking.  Very  often  some  of  these 
patients  are  intemperate  in  other  directions,  or  they 
may  also  be  addicted  to  the  use  of  alcohol.  In  my 
experience,  the  majority  of  those  who  suffer  from  the 


Coffee  Addiction  307 

results  of  the  '  coffee  habit  *  drink  alcoholic  or  malt 
liquors  either  only  occasionally  or  not  at  all,  being 
satisfied  with  the  cerebral  stimulation  produced  by 
the  coffee.  It  is  not  unusual  for  many  of  them  to 
drink  from  six  to  eight  cupfuls  of  coffee  daily,  while 
some  have  been  known  to  drink  from  twelve  to  four- 
teen cupfuls  in  as  many  hours.  In  some,  symptoms 
of  chronic  poisoning  may  result  from  three  or  four 
cupfuls  daily.  Such  persons  do  not  take  suitable 
or  sufficient  food,  and  as  coffee  possesses  but  little 
nutritive  value,  they  ultimately  show  unmistakable 
evidence  of  malnutrition  in  addition  to  their  other 
symptoms. 

"  In  this  connection  it  is  interesting  to  mention 
that  physiologic  experiment  has  shown  that  after 
substituting  infusion  of  coffee  for  water,  inanition 
became  more  marked  in  those  animals  fed  only  upon 
hydrocarbons,  while  in  those  fed  exclusively  upon 
meat,  the  malnutrition  was  not  so  pronounced.  This 
fact  may  explain  the  loss  of  weight  among  the  poor 
patients  of  this  class,  whose  dietary  consists  princi- 
pally of  carbonaceous  food. 

"There  is  a  peculiar  difference  between  the  symp- 
toms of  acute  and  chronic  coffee-poisoning.  In  the 
former,  when  coffee  is  taken  in  large  doses  by  persons 
unaccustomed  to  its  use,  it  produces  excitability  to 
the  degree  of  delirium,  etc.  In  the  latter,  which  is  of 
greater  importance  on  account  of  its  more  frequent 


3o8  Morphinism 

occurrence,  the  toxemia  manifests  itself  as  a  depres- 
sive form  of  neurasthenia.  In  brief,  the  symptoms 
of  chronic  coffeeism  are  indicative  of  interference 
with  the  nutrition  of  the  cells  of  the  cerebrospinal 
system  resulting  from  overstimulation  and  auto- 
toxemia,  and  correspond  very  closely  with  the  symp- 
toms of  chronic  alcoholism,  for  which  it  is  so  often 
mistaken.  Age,  sex,  temperament,  constitution, 
and  occupation,  which  occasion  individual  suscepti- 
bility, must  be  considered  prominent  predisposing 
factors  in  this  disease.  For  obvious  reasons,  women 
are  more  addicted  to  the  coffee  habit  than  men." 

Several  Continental  observers  have  described 
coffee-poisoning  occurring  among  poor  people,  and 
probably  arising  from  strong  infusions  of  coffee 
used  in  great  excess  with  food.  The  symptoms  are 
intense  nausea,  vomiting,  acid  eructations,  with 
cramps  of  the  muscles  of  the  legs,  insomnia,  and 
emaciation. 

These  symptoms  have  been  referred  to  alcohol, 
and  seem  to  be  identical  with  poisoning  from  this 
source.  The  removal  of  coffee  is  followed  by  their 
disappearance,  showing  that  this  was  the  particular 
cause.  Where  alcohol  is  not  used,  these  symptoms 
indicate  caffeinism,  and  are  preceded  by  trembling 
of  the  legs  and  arms,  twitching  of  the  lips  and  mus- 
cles of  the  face,  dilated  nostrils,  and  increased  heart's 
action.     Many  people  believe  that  coffee  contains 


Coffee  Addiction  309 

some  food  elements,  and  hence  its  substitution  where 
food  is  scarce  and  of  imperfect  quaHty.  In  such 
cases  a  distaste  for  solid  food  appears  very  early,  and 
the  patient  confines  his  diet  to  bread  and  other  cereals 
soaked  in  coffee. 

The  differential  diagnosis  between  caff einism  and 
alcoholic  gastritis  is  sometimes  difficult.  The  ema- 
ciation and  extreme  nervousness,  in  addition  to  the 
other  symptoms,  are  the  most  prominent.  Dyspep- 
sia and  nausea  occurring  in  both  cases  will  decline 
from  the  removal  of  one  or  the  other,  and  in  this  way 
the  particular  cause  can  be  determined. 

Some  of  these  persons  drink  beer  or  wine  at  meals 
in  addition  to  large  quantities  of  coffee.  Probably  the 
effects  of  alcohol  and  coffee  neutralize  each  other 
for  the  time.  But  both  are  very  serious,  and  require 
active  treatment. 

The  virtues  of  ccrffee  are  found  by  experiment  to 
be  entirely  subjective,  and  to  depend  upon  its  ex- 
hilarant  action  upon  the  mental  processes.  The 
popular  idea  that  it  takes  the  place  of  food  and  in- 
creases the  power  for  work  without  corresponding 
tissue  change  is  found  to  be  erroneous.  Large  ex- 
perience shows  that  the  use  of  coffee  should  be 
inquired  into  in  all  cases  of  nervous  disease,  and  that 
its  influence  should  be  studied  as  carefully  as  that  of 
alcohol  or  opium. 

Its  effects  upon  the  nervous  system  of  children 


3IO  Morphinism 

have  been  noted  in  many  instances  to  be  delete- 
rious. Many  children  who  exhibit  precocity  and 
functional  exaltation  are  found  to  be  using  coffee. 
In  some  instances  it  is  decidedly  poisonous.  It 
should  always  be  remembered  that  the  deUcate 
nervous  system  of  a  child  is  peculiarly  susceptible 
to  the  effects  of  coffee.  Often  neurasthenics  and 
overworked  and  underfed  men  and  women  suffer 
seriously  from  coffee,  which  to  them  seems  to  cover 
up  and  conceal  the  real  condition. 

In  the  treatment  of  these  cases  immediate  and 
total  abstinence  should  be  the  rule.  It  is  possible  to 
use  cocoa  as  a  substitute  for  a  time,  and  thus  relieve 
the  withdrawal  symptoms,  but  usually  baths,  care- 
ful a^ttention  to  the  diet  and  excretions,  together 
with  prolonged  rest  cure,  are  most  effectual. 


CHAPTER  XIV 
TEA  INEBRIETY 

Is  Increasing.  A  Most  Complex  Neurosis  Affecting  Large  Num- 
bers of  Women.  Peculiar  Symptoms  which  are  Often  Mistaken 
for  Other  Diseases.     Treatment  and  Prevention. 

Tea  inebriety  is  one  of  those  peculiar  addictions 
that  come  occasionally  under  medical  notice.  The 
fact  is  well  recognized  in  all  medical  circles  that  a 
considerable  number  of  persons  seriously  injure 
themselves  by  the  excessive  use  of  tea.  The  usual 
symptoms  are  gastric  derangements,  neuralgias, 
with  muscular  twitchings  and  tremblings,  and  great 
irritability  with  hyperexcitabiHty. 

In  some  instances  delusions  of  fear,  particularly 
of  injury  and  of  some  chronic  disease  and  sudden 
death,  are  common.  There  are  often  hallucinations 
of  voices  and  threatening  sounds  at  night.  Painful 
insomnia,  nightmare,  and  bad  dreams  are  the  most 
common  symptoms.  Many  of  the  victims  are  single 
women,  past  middle  life;  others  are  neurotic  men, 
suffering  from  neurasthenia  and  various  forms  of 
nerve-exhaustion. 

In  many  of  these  cases  the  physician  is  called  to 
treat  sudden  attacks  of  delirium  and  delusions  of 

311 


312  Morphinism 

some  extraordinary  character,  such  as  the  appearance 
of  tumors  and  disease,  or  infection  or  contagious 
poisons,  all  based  upon  subjective  symptoms.  These 
conditions  last  several  days  with  varying  intensity. 
If  tea  is  suspected  as  the  cause,  and  removed,  these 
states  rapidly  pass  away.  If  not,  they  continue, 
but  are  amenable  to  treatment. 

Digestive  disturbances,  of  which  constipation  is 
very  common,  are  present.  Non-assimilation  of 
food  from  failure  of  the  digestion  is  followed  by  star- 
vation and  loss  of  flesh.  The  heart  is  affected,  and 
states  of  exhaustion  from  the  slightest  exertion  are 
common. 

The  action  of  thein  affecting  the  cerebral  centers 
varies  widely,  although  its  first  effect  is  primarily  on 
the  nervous  system,  and  secondarily  on  the  organ- 
ism. The  tannic  acid  in  the  tea  acts  as  an  astrin- 
gent, disturbing  digestion  and  breaking  up  the  nor- 
mal physiologic  changes.  It  is  probable  that  the 
essential  oils,  besides  disturbing  the  digestion,  have 
a  special  action  on  the  brain-centers,  producing  ex- 
citement of  the  circulation,  rapid  pulse,  and  later 
muscular  tremor.  It  is  said  by  some  authorities 
that  the  injury  from  tea-drinking  is  due  indirectly  to 
the  metamorphosis  of  the  nutrient  elements  as 
toxic  agents  and  their  retention  and  action  as 
poisonous  products. 

The  late  Dr.  Wood,  in  some  experiments,  showed 


Tea  Inebriety 


313 


that  tannin  rendered  certain  digestive  fluids  inert, 
and  that  through  chemical  changes  these  formed  by- 
products that  were  poisonous.  Persons  using  large 
quantities  of  tea  show  a  decrease  in  the  amoimt  of 
carbon  dioxid  expired.  The  sensory  faculties  are 
diminished  and  the  power  of  control  is  lessened. 
The  vital  forces  seemingly  are  diverted  and  changed, 
although  the  feeling  of  greater  strength  is  present. 
Dr.  Wood  gave  a  table  of  the  action  of  thein  and 
cafiein]  which  gives  some  idea  of  their  influence  on 
the  organism: 


Thein. 

Affects  sensory  system. 

Produces  netiralgia. 

Causes  spasms. 

Causes  convulsions. 

Impairs  or  abolishes  nasal  re- 
flex. 

Diminishes  temperature. 

Is  astringent. 

Dilates  capillaries  of  splanchnic 
arcade. 

Mildly  diiiretic. 

Causes  irregular  and  feeble  car- 
diac action. 

Causes  sinking  sensation  in 
epigastrium. 

Causes  sick  headache. 

Opposes  active  nutrition. 


Caffein. 
Affects  motor  system. 
Does  not. 

Does  so  late,  if  at  all. 
Does  so  late,  if  at  all. 
Does  so  late,  if  at  all. 

Increases  temperature. 
Is  relaxing. 
Contracts  the  same. 

Is  powerftdly  so. 
Causes  strong  and  regular  car- 
diac action. 
Relieves  the  same. 

Relieves  the  same. 
Increases  nutrition  and  tone  of 
the  system. 


This  table,  giving  a  comparative  simimary  of  the 
effects  of  tea,  makes  it  clear  that  its  addiction  is  a 


314  Morphinism 

very  serious  matter.  Many  obscure  neurotic  cases 
will  be  found  to  proceed  from  the  poison  of  tea. 

The  treatment  of  cases  of  this  kind  is  very  largely 
by  active  hygienic  measures,  supplemented  with 
mineral  tonics  and  bitter  barks,  and  also  acid 
drinks.  Much  attention  should  be  paid  to  the 
action  of  the  bowels  and  skin,  which  in  all  cases 
are  seriously  disturbed. 

In  some  parts  of  Europe  tea  cigarettes  have  been 
made,  and  used  for  their  effects,  the  action  being 
the  same  substantially  as  that  from  the  infusion. 
Cigarettes  are  made  in  this  country,  and  used  in  some 
circles,  but  are  not  popular. 

Drug-takers  sometimes  turn  to  tea  either  in  the 
form  of  a  cigarette  or  an  infusion.  While  the  effects 
are  pleasing,  they  are  so  transient  as  to  be  imsatis- 
factory.  Tea  has  been  used  as  a  substitute  in  the 
withdrawal  of  opium,  and  in  alcoholic  cases,  but  in 
most  instances  it  produces  more  general  nerve  dis- 
turbances than  it  allays. 

The  continuous  and  excessive  use  of  tea  may  be 
considered  not  only  an  active  cause  of  serious  neuro- 
sis, but  also  a  prominent  symptom  of  psychosis  which 
may  merge  into  many  and  complex  disorders.  To 
some  persons  tea  is  a  dangerous  stimulant,  and  leads 
rapidly  to  other  disorders,  which  are  not  recognized 
as  coming  from  this  source. 


CHAPTER  XV 

TOBACCO  INEBRIETY 

The  Poison  of  Tobacco.  Symptoms  of  Tobacco  Intoxication. 
Often  Associated  with  Alcohol  and  Other  Drugs.  Tobacco  Nar- 
cotic Poisoning.  Its  Use  in  Any  Form  Followed  by  Debility  and 
Exhaustion.  Tobacco  to  be  Abandoned  in  the  Treatment  of  Drug 
Addictions.  Often  an  Exciting  Cause  to  Other  Narcosis.  Very 
Complex  and  Very  Difficult  of  Treatment.  The  Cigarette  Habit. 
Its  Prevalence  and  Danger  as  Noted  by  Statistics.  Analysis  of  the 
Cigarette.  Poisons  which  It  Contains.  Its  Immediate  Effects. 
The  Treatment  of  Cigarette  Disease.  Medicolegal  Questions 
which  Come  from  It. 

Every  one  is  familiar  with  the  tobacco  addiction ; 
whether  in  the  form  of  cigars  and  cigarettes  or  used 
for  chewing,  its  effects  are  about  the  same.  There 
can  be  no  doubt  that  the  use  of  tobacco  is  poisonous. 

Its  effects  are  very  evident  in  its  first  use.  The 
pale  face,  the  clammy  skin,  the  tremulous  heart, 
intense  nausea,  and  muscular  relaxation  are  usual 
symptoms.  Later,  when  the  system  is  damaged 
by  long  use,  the  anemia,  muscular  trembling,  gen- 
eral nervousness  with  debility,  and  defective  sensory 
fiuictions,  are  all  unmistakable  symptoms. 

There  are  many  cases  on  record  of  tobacco  intox- 
ication in  which  the  person  both  smoked  and  chewed, 
and  induced  a  state  of  stupor  with  extreme  debility. 

315 


3 1 6  Morphinism 

Very  few  persons  come  under  medical  care  for  this 
specific  addiction  who  use  tobacco  to  excess,  but 
there  is  no  doubt  that  they  are  physically  disabled 
and  suffering  from  a  peculiar  class  of  symptoms 
which  should  require  active  treatment. 

The  tobacco  addiction  is  usually  associated  with 
alcohol  or  other  drugs,  hence  the  tobacco  disability 
is  seldom  considered.  In  reality,  tobacco  is  a  nar- 
cotic poison,  and  its  use  is  not  only  dangerous,  but  it 
is  certain  to  be  followed  with  debility,  mental  per- 
version, and  exhaustion. 

It  is  an  interesting  study  to  know  how  far  the 
tobacco  habitu^  is  impaired  mentally,  and  how  far 
he  could  be  called  responsible  for  his  conduct  and 
thought.  In  the  treatment  of  all  drug  addictions 
the  tobacco  complication  should  always  be  recog- 
nized and  its  use  abandoned  at  the  earliest  possible 
moment.  There  is  associated  with  it  a  very  pro- 
nounced psychic  element,  which  requires  more  men- 
tal treatment  than  in  other  addictions. 

In  some  instances  the  removal  of  the  tobacco 
addiction  has  been  followed  by  the  restoration  of  the 
patient.  This  one  drug  seems  to  have  been  the  ex- 
citing cause  of  all  the  others.  At  all  events,  it  con- 
tributes more  or  less  in  these  neurotic  cases  to  the 
growth  and  development  of  narcosis  from  many 
other  drugs. 

Recently  oculists  have  called  attention  to  amblyo- 


Tobacco  Inebriety  317 

pia  from  tobacco,  and  described  it  as  a  very  common 
symptom.  Railroads  and  companies  employing 
men  where  clear  vision  is  required  find  the  tobacco- 
user  defective  and  incapacitated.  Statistics  show 
that  studentjg  and  brain-workers  who  use  tobacco 
have  less  vigor,  both  mental  and  physical,  and  are 
more  liable  to  disease. 

The  efforts  of  quacks  to  treat  the  tobacco  addic- 
tion have  created  the  impression  that  it  is  easily 
curable.  This  is  untrue,  because  of  its  complex 
character  and  the  psychopathic  conditions  which 
enter  into  the  causation.  The  direct  poisonous 
action  of  nicotin  can  be  removed,  but  the  conditions 
which  provoked  and  continued  its  use  reqtiire  pro- 
longed, active  treatment. 

Recently  the  danger  from  cigarette  smoking  has 
come  into  considerable  prominence.  Dr.  French 
has  stated  this  peril  imder  three  heads: 

First,  cigarettes  are  used  to  very  large  extent  by 
boys  and  young  men. 

Second,  their  attractive  size  and  mild  after-effects 
encourage  their  constant  use. 

Third,  the  smoke  is  inhaled  more  than  in  any  other 
way  of  using  tobacco. 

Several  statistical  reports  have  clearly  pointed  out 
that  the  cigarette  smoker  is  deficient  physically  and 
mentally  compared  with  the  non-user.  Measure- 
ments of  college  men  in  Yale,  Amherst,  and  other 


31 8  Morphinism 

large  schools  show  that  the  cigarette  smoker  is  defi- 
cient in  his  studies  and  physically  weaker  than  the 
average  student  who  abstains  from  tobacco.  In 
the  Polytechnic  School  in  France  all  the  cigarette 
smokers  were  inferior,  hence  the  government  pro- 
hibited students  of  all  public  schools  from  using 
cigarettes.  Both  at  West  Point  and  Annapolis 
cigarette  smoking  is  prohibited.  The  special  influ- 
ence seems  to  be  on  the  heart's  action  and  diminution 
of  the  senses  and  mental  activities.  Other  observa- 
tions made  show  that  the  use  of  cigarettes  is  followed 
by  disordered  nutrition,  retarded  growth,  general 
dulness  of  the  senses,  and,  particularly,  failure  of  the 
eyesight.  Several  papers  have  been  read  describing 
these  conditions  and  tracing  them  particularly  to  the 
use  of  the  cigarette. 

Analysis  of  the  cigarette  has  pointed  out  the  pres- 
ence of  alkaloids  of  tobacco  which  are  probably  the 
active  causes  of  these  conditions.  One  authority 
states  that  cigarette  smoking  is  particularly  poison- 
ous from  the  fact  that  larger  surfaces  for  the  absorp- 
tion of  the  tobacco  smoke  are  exposed  in  the  use  of 
cigarettes.  The  great  volatility  of  nicotin,  according 
to  Dr.  Reynolds,  and  the  presence  of  numerous 
other  poisonous  substances  in  tobacco  smoke  indicate 
that  nicotin  is  not  the  only  active  principle  at  work. 
It  is  probable  that  the  poisonous  effect  of  tobacco, 
not  only  on  the  optic  nerve,  but  also  on  the  system 


Tobacco  Inebriety  319 

generally,  is  increased  by  volatile  alkaloids  liberated 
during  its  combustion.  It  seems  not  unlikely  that 
pyridin,  and  less  markedly  collidin,  should  be  re- 
garded as  active  toxic  agents  in  this  respect.  It  is 
possible  that  nicotin  or  one  or  more  of  the  many 
principles  freely  present  in  tobacco  smoke  liberates 
some  toxic  influence  which  must  be  held  accountable 
for  the  disease  amblyopia,  which,  in  other  words, 
depends  on  a  species  of  autointoxication.  Hyper- 
esthesia of  the  retina  is  one  of  the  early  symptoms  of 
tobacco  poisoning,  and  is  soon  followed  by  the  ap- 
pearance of  a  smokiness  in  the  center  of  the  field, 
which  is  greatly  increased  on  exposure  to  bright  illu- 
mination. After  a  while  small  type  becomes  indis- 
tinguishable, and  a  network  or  veil-like  substance 
appears  near  the  center  of  the  field,  obscuring  a 
portion  of  long  words,  and  making  it  impossible  to 
read  with  satisfaction.  Soon  letters  cannot  be  seen 
even  with  the  aid  of  glasses.  The  color-sense  is 
so  reduced  that  neither  red  nor  green  are  dis- 
cernible. It  is  this  failure  of  the  sight,  due  directly 
to  tobacco  and  not  recognized  by  the  victim,  that 
makes  it  exceedingly  dangerous  for  persons  whose 
work  depends  upon  their  powers  of  vision. 

Cigarette  smoking  possesses  these  and  other  dan- 
gers common  to  the  tobacco  habit. 

A  fact  which  is  overlooked  is  that  tobacco  is  rich 
in  nitrate  of  potash,  which  greatly  assists  in  the  pro- 


320  Morphinism 

cess  of  combustion  in  smoking,  and  is  converted  into 
oxid  of  potash,  the  caustic  properties  of  which  are 
apparent  in  the  mouths  and  throats  of  all  smokers. 

The  charge  against  cigarettes  is  that  they  contain 
empyreumatic  oil,  nicotin,  pyridin,  and  caustic  pot- 
ash in  the  smoke  which  comes  from  them,  and,  owing 
to  their  small  size  and  mildness,  are  used  in  such 
numbers  that  a  large  quantity  of  this  smoke  is 
inhaled,  which  more  than  equals  the  high  percentage 
of  nicotin  in  other  forms  of  smoking  tobacco. 

Dr.  Reynolds  says  an  agent  which  can  produce 
cardiac  disturbances,  and  so  excite  the  brain  as  to 
make  it  impossible  to  concentrate  the  mind  on  one 
subject,  followed  by  failing  memory,  incontinuity 
of  thought,  nervous  excitement,  with  physical  debil- 
ity and  muscular  tremors,  is  dangerous  beyond  all 
estimate,  particularly  for  young  people. 

While  the  facts  are  not  all  clearly  known  at  present, 
it  is  very  evident  that  cigarette  smoking  is  danger- 
ous, especially  for  young  persons.  The  effects  of 
tobacco  on  all  persons  are  depressing  and  more  or 
less  injurious. 

The  treatment  of  the  cigarette  disease  must  be 
largely  by  hygienic  measures  and  powerful  mental 
impressions  to  counteract,  if  possible,  the  fascination 
of  the  cigarette.  Various  tonic  drugs  may  be  used  to 
counteract  the  other  conditions.  Nux  vomica  will 
probably  be  found  the  most  valuable,  given  in  small 


Tobacco  Inebriety  321 

doses  often  repeated.  Salines  may  be  very  influen- 
tial in  restoring  the  healthy  metabolism  of  the  body. 
The  open  air,  exercise,  and  nutrition  should  be  para- 
mount in  all  treatment. 

Some  interesting  questions  have  been  proposed 
concerning  the  truthfulness  and  accuracy  of  persons 
who  use  tobacco  in  excess.  In  all  probability  there 
are  cases  in  which  the  sensory  impressions  and  the 
reasoning  are  very  seriously  impaired,  and  persons  of 
this  class  are  not  good  witnesses  and  cannot  be  de- 
pended upon  concerning  facts  which  have  occurred 
some  time  before.  Their  memory  is  faulty,  and  both 
sight  and  hearing  are  equally  depressed,  hence  it  is 
a  very  doubtful  matter  if  their  statements  can  be 
depended  upon  in  matters  requiring  great  accuracy. 
At  all  events,  the  excessive  user  of  tobacco  is  not  an 
accurate,  reliable  man  in  all  cases.  If  he  is,  it  is  an 
exception  to  the  rule. 


CHAPTER  XVI 
ETHER  INEBRIETY 

Confined  to  Certain  Localities.  Seen  in  North  of  Ireland.  Its 
Effects.  Easily  Discovered.  Cordials  Containing  Ethers  Used. 
Cordials  are  Adulterated  Extracts.  Ethers  not  always  Stimu- 
lants.    Often  Narcotics.     Always  Dangerous. 

The  use  of  ether  as  a  beverage  has  so  far  been 
noted  in  certain  distinct  localities  and  is  appar- 
ently dependent  on  certain  special  local  condi- 
tions. 

The  most  prominent  use  of  ether  as  a  beverage  was 
noted  in  a  little  town  in  the  north  of  Ireland.  In 
some  lumber  and  mining  villages  in  this  country 
cheap  sulphuric  ethers  have  been  sold  as  drinks,  and 
some  cases  of  addiction  have  followed. 

It  is  found  that  cheap  alcoholic  ethers  have  a  pe- 
culiar fascination  for  certain  persons  because  of  the 
rapid  tumultuous  exhilaration  and  good  feeling 
which  follow  their  use. 

In  a  village  in  the  north  of  Ireland  some  dealers 
put  on  the  market  a  cheap  methylated  spirit  which 
was  sold  for  one  cent  a  glass.  Its  effects  were  so 
pleasing  that  it  immediately  became  popular.  Beer 
and  stronger  spirits  were  abandoned,  and  these  ether 

322 


Ether  Inebriety  323 

drinks  were  substituted.  Poor  men  on  their  return 
from  a  hard  day's  work  could  become  deliriously 
exhilarated  for  a  few  cents,  then  go  home  and  sleep 
it  off,  and  be  apparently  uninjured  the  next  day. 
Hundreds  of  new  victims  to  this  mania  followed.  A 
widespread  publicity  was  attracted  to  the  place,  and 
after  a  careful  examination  the  government  placed 
ether  among  the  list  of  poisons  which  the  law  pun- 
ishes by  a  severe  penalty  if  sold  to  any  but  responsi- 
ble persons  for  legitimate  purposes. 

The  late  Drs.  Hart  and  Kerr  made  a  careful  ex- 
amination and  study  of  this  new  drug  mania,  and 
concluded  that,  notwithstanding  the  prohibition, 
ether-drinking  was  slowly  increasing  in  other  parts 
of  the  British  Isles.  Dr.  Kerr  was  surprised  that  it 
had  not  spread  more  rapidly,  and  he  has  expressed 
an  opinion  that  unless  strong  restrictive  measures 
were  used  ether-drinking  was  destined  to  become  a 
very  prominent  disease. 

The  symptoms  are  those  of  sudden,  rapid  intoxica- 
tion, the  excited  stage  of  which  is  prolonged,  and 
usually  of  a  hilarious,  joyous  type,  rarely  leading  to 
violent  acts,  yet  liable,  if  opposition  is  offered,  to  do 
so  at  any  moment.  There  seems  to  be  a  contagious 
excitement  with  extreme  exhilaration  of  the  senses 
and  imagination.  In  a  short  time  this  is  followed  by 
dulness,  which  rapidly  merges  into  stupor  and  sleep. 
In  the  little  town  mentioned  parties  of  workmen 


324  Morphinism 

would  fill  the  air  with  laughter  and  joyous  shouts, 
and  in  the  course  of  half  an  hour  be  found  stupid  and 
asleep  on  the  roadside.  They  would  then  recover 
and  go  away  depressed.  After  a  time  this  depression 
deepened  into  melancholia  and  general  debility,  in 
which  the  digestion  and  sleep  stiffered  most  acutely. 

The  few  cases  which  have  been  studied  are  mostly 
those  of  a  previous  alcoholic  and  opium  addiction. 
Ether  was  taken  up  as  more  pleasant  and  agreeable 
than  the  other  addictions.  The  mind  in  all  these 
cases  became  more  or  less  impaired,  and  in  the  end 
very  serious  troubles  followed,  which  were  extremely 
difficult  to  cure. 

Recently  among  the  better  classes  ether-drinking 
has  appeared  in  the  use  of  proprietary  preparations 
containing  ether  disguised  by  pleasant  flavoring 
substances.  These  are  used  by  fashionable  ladies 
and  by  men  of  leisure  who  wish  to  appear  particu- 
larly brilliant  in  conversation  on  some  special  occa- 
sions. One  firm  in  London,  England,  sells  enor- 
mous quantities  of  two-  and  four-ounce  mixtures 
which  are  used  for  this  purpose.  Probably  after 
a  time  its  effects  wear  off  and  other  narcotics  are 
substituted. 

Many  of  these  addictions  are  secret,  and  are  fol- 
lowed by  very  obscure  symptoms,  particularly  of 
hyperesthesia  and  anesthesia  of  different  parts  of  the 
nervous  system.     The  effects  are  so  prominent  that 


Ether  Inebriety  325 

it  is  no  doubt  readily  traced,  and  can  be  easily  dis- 
covered where  it  is  used  for  any  length  of  time. 

Recently  attention  has  been  called  to  the  promi- 
nence of  so-called  "cordials"  with  fanciful  foreign 
names,  sold  in  this  country,  supposed  to  be  alcoholic 
combinations  of  great  purity  and  value.  Many  in- 
stances have  been  reported  of  peculiar  exhilaration 
and  stupor  following  their  use.  Most  of  these  cases 
are  of  persons  who  use  daily  or  at  intervals  these 
peculiar  drinks,  and  seem  to  be  particularly  exhilar- 
ated in  the  first  stage.  Later  stupor  and  profound 
sleep  follow.  On  recovery,  headache,  depression, 
and  irritability  of  the  stomach  follow,  for  which 
the  cordial  is  taken  again.  The  exhilaration  becomes 
shorter  and  the  stupor  and  sleep  more  deep,  followed 
by  greater  irritation  and  debility.  The  exhilaration 
seems  to  be  of  a  more  esthetic  character  than  that 
from  the  coarser  alcohols,  and  the  sleep  is  more  pro- 
found. The  after-effects  are  practically  the  same. 
Some  examinations  have  shown  that  these  cor- 
dials are  cheap  ethers  fortified  with  opium  extracts, 
and  are  particularly  dangerous  not  only  in  their 
effects  on  the  system,  but  in  the  fascinating  ad- 
diction which  follows.  Several  of  these  cordials  are 
supposed  to  be  manufactured  abroad,  but  are  un- 
doubtedly made  here,  and  are  evidently  a  combina- 
tion of  opium  and  ethers.  The  prevalent  opinion 
that  ethers  are  purely  stimulant  and  very  evanescent 


326  Morphinism 

in  their  action  is  not  sustained  by  cKnical  experi- 
ence. In  certain  instances  they  have  been  found  to 
be  profoundly  narcotic.  Whether  this  is  due  to  some 
pecuHarity  of  the  person  or  to  extreme  susceptibiHty, 
or  to  some  quality  of  the  ether  itself,  is  imknown. 
At  all  events,  they  may  be  classed  among  the  nar- 
cotics whose  effects  are  particularly  fascinating  and 
dangerous  for  most  persons. 


CHAPTER  XVII 
ADDICTIONS  FROM  OTHER  DRUGS 

Arsenic.     Trional.     Antipyrin.     Ginger.     Cologne.     Gelsemiunt. 
Sulfonal.     Paraldehyd.     Lavender.     Capsicum. 

Arsenic  is  used  as  an  addiction  in  several  coun- 
tries. In  Austria  there  appear  to  be  many  towns  in 
which  arsenic  is  used  for  its  stimulating  effect. 
Probably  among  the  very  poor  it  was  foimd  to  have 
a  certain  stimulating  action  on  the  brain  and  nervous 
system,  hence  its  use  was  continued. 

Dr.  Oswald  writes  that  in  the  city  of  Gratz  a  large 
number  of  persons  use  arsenic  as  they  would  tea  or 
coffee.  It  gives  them  a  certain  buoyancy  and  sense 
of  elation,  and  a  clearness  of  intellect  that  is  very  un- 
usual. After  the  effects  have  passed  off  they  become 
moody,  melancholic,  and  depressed,  but  commonly 
they  do  not  permit  themselves  to  give  up  the  use  of 
the  drug,  hence  they  go  about  with  a  buoyant  dis- 
position and  equable  temper,  and  seem  to  have  much 
enjoyment  in  life. 

A  clear,  waxHke  complexion  is  a  very  characteris- 
tic symptom,  and  after  a  time  some  digestive  disturb- 
ances appear  or  some  nervous  trembling.     There  can 

327 


328  Morphinism 

be  no  doubt  that  there  are  a  number  of  persons  using 
arsenic  secretly  for  its  tonic  effects. 

In  the  later  stages,  after  the  drug  has  been  used  a 
long  time,  there  is  a  pectiliar  tremor  noticeable, 
which  can  be  differentiated  from  that  which  follows 
from  the  use  of  alcohol  or  lead.  Associated  with  this 
are  frequently  found  palsies  of  the  extensors,  neuritis, 
and  hemiplegias,  with  stiffness  of  joints.  The  glassy 
eye  is  another  symptom ;  also  a  metallic  odor,  which 
is  noted  in  the  perspiration.  The  skin  becomes 
pearly  white  and  the  face  plump,  with  the  wrinkles 
all  smoothed  out. 

There  is  a  certain  tolerance  which  grows  from  the 
use  of  this  drug  permitting  very  large  doses  to  be 
taken  daily.  A  case  of  this  kind  came  under  the 
author's  care.  A  man  in  middle  life  acknowledged 
that  he  was  using  twenty  grains  daily,  and  wished  to 
abandon  it.  He  was  apparently  vigorous  and  healthy, 
and  except  for  a  certain  paleness  and  a  glassy  eye 
would  have  been  considered  in  perfect  health.  He 
suffered  from  indigestion,  and  on  attempting  to 
abandon  the  drug  was  insomniac  and  had  muscular 
trembling.  This  condition  created  fears  of  sudden 
death  and  dread  of  injury  from  accident.  He  was  a 
traveling  man,  and  found  his  power  of  endurance 
diminishing  and  had  frequent  fiutterings  of  the  heart, 
with  stiffness  of  the  legs  and  lower  extremities.  These 
symptoms  alarmed  him. 


Arsenic  329 

Baths,  mineral  tonics,  such  as  the  soda,  iron,  and 
phosphorous  preparations,  also  bitter  tonics  and  rest, 
enabled  the  amount  to  be  reduced  to  five  grains  a 
day.  During  treatment  he  was  melancholy  and  de- 
pressed, and  grew  more  and  more  retiring  in  his  man- 
ner and  secret  in  his  conduct.  Finally  he  claimed  to 
have  received  a  special  despatch  to  attend  to  some 
business  in  a  distant  town,  and  was  never  seen  again. 
In  all  probability  he  relapsed. 

There  is  a  well-grotuided  behef  that  a  large  number 
of  society  women  and  others  use  arsenic  for  its  effect 
on  the  skin,  and  receive  from  it  a  certain  buoyancy 
and  exhilaration  which  at  first  are  agreeable.  For- 
tunately these  cases  are  not  common,  and  when  they 
come  under  medical  care  the  symptoms  are  easily 
determined  and  the  general  plan  of  treatment  is  the 
same  as  in  that  of  all  other  addictions. 

Not  infrequently  postmortem  analysis  reveals 
arsenic,  and  a  suspicion  that  this  drug  has  been  used 
for  criminal  purposes  is  excited.  A  more  careful 
examination  discloses  the  fact  that  it  has  been  used 
medicinally  or  for  some  tonic  effect.  A  prominent 
physician  used  this  drug  for  many  years,  then  sud- 
denly developed  obscure  symptoms  of  paralysis,  ex- 
haustion, and  general  anemia,  which  ended  in  death. 
There  was  no  suspicion  at  the  time  that  the  real 
cause  was  arsenic.     Later,  in  settling  up  his  estate. 


330  Morphinism 

the  bills  for  arsenic  showed  him  to  have  been  ad- 
dicted to  its  use. 

There  are,  no  doubt,  certain  persons  who  derive 
great  relief  and  vigor  from  this  drug,  and  use  it 
for  a  time  without  showing  any  poisonous  effects. 
There  is  some  peculiar  predisposition  in  the  system 
which  makes  the  drug  tolerable  and  the  person  im- 
mune to  its  poisonous  action.  There  is  probably  no 
remedy  more  widely  used  as  a  tonic,  especially  in 
malarious  regions,  and  the  possibility  of  its  addic- 
tion should  never  be  overlooked. 

Trional  is  a  drug  which  has  come  very  much  into 
vogue  during  the  last  few  years.  On  its  first  intro- 
duction it  was  regarded  by  physicians  as  an  abso- 
lutely safe  hypnotic.  There  have  been,  however, 
cases  in  which  some  curious  ill  effects  have  been 
noticed.  Stewart  Hart  quoted  several  such  in- 
stances, and  describes  a  case*  tmder  his  own  care  in 
which  there  were  neuritis  and  hematoporphyrinuria. 

The  patient  was  a  lady,  aged  fifty,  in  wealthy 
circumstances,  who  had  suffered  from  insomnia  and 
dyspepsia  for  many  years.  She  had  taken  a  dose  of 
fifteen  grains  of  trional  every  other  day,  though  occa- 
sionally intermitting  for  three  or  four  days.  After 
about  two  months  she  suddenly  developed  severe 
abdominal  pain  of  a  colicky  character,  with  extreme 
nausea  and  vomiting.  There  was  no  pyrexia,  ab- 
*  "  Amer.  Jour.  Med.  Sci.,"  April,  1901. 


Trional  331 

dominal  tenderness,  nor  distention.  These  symp- 
toms lasted  for  several  days,  rendering  rectal  ali- 
mentation necessary.  The  administration  of  trional 
was  stopped,  and  morphin  administered  hypoder- 
mically.  The  urine,  which  had  hitherto  been  normal, 
became  dark  red,  and  contained  a  trace  of  albumin. 
One  day  only  twelve  ounces  of  black  urine  were 
passed.  No  blood  was  present.  This  specimen 
gave  the  typical  spectrum  of  hematoporphyrin.  The 
pulse  became  intermittent,  and  an  apex  murmur 
was  heard.  A  few  days  later  there  was  tingling  in 
both  arms  and  the  knee-jerks  were  absent.  There 
was  pain  in  the  left  elbow  and  the  legs  were  weak. 
Tactile  and  thermic  sensations  were  diminished,  but 
not  absent.  Paresis  appeared  in  the  extensor  mus- 
cles of  the  left  arm  and  leg.  Reaction  of  degenera- 
tion was  obtained.  From  these  symptoms  the 
patient  slowly  and  gradually  improved,  and  the 
heart  condition  also  cleared  up.  The  writer  con- 
siders that  trional  was  the  initial  cause  of  this 
curious  combination  of  gastric  and  neuritic  symp- 
toms. 

As  is  well  known,  sulfonal  is  very  apt  to  produce 
hematoporphyrinuria,  and  the  similarity  in  chemical 
constitution  of  trional  and  sulfonal  warrants  such  a 
supposition.  The  exact  cause  and  mode  of  the 
production  of  the  hematoporphyrinuria  by  this 
group  of  compoimds  is  not  as  yet  known.     It  has 


332  Morphinism 

been  suggested  that  some  irritation  is  produced  in 
the  kidneys,  others  think  that  the  presence  of  hema- 
toporphyrinuria  is  due  to  changes  in  the  central 
nervous  system.  As  regards  the  neuritis,  it  has  also 
come  to  be  recognized  that  the  increased  exhibition 
of  coal-tar  products  within  the  last  few  years  has 
apparently  been  followed  by  a  relative  increase  in 
the  number  of  cases  showing  neuritic  symptoms. 

Antipyria. — Recently  several  cases  have  been  re- 
ported of  persons  who  used  antipyrin  in  large  doses 
continuously.  At  first  pleasing  sleep  followed ;  then 
broken,  troubled  narcotism,  associated  with  dreams 
and  dread  of  dying,  followed.  In  these  cases  inani- 
tion, anemia,  cardiac  failure,  and  general  symptoms 
of  great  depression  point  to  the  real  cause. 

Many  of  these  cases  are  associated  with  other 
drug-taking,  and  after  a  time  this  drug  is  abandoned, 
the  symptoms  becoming  unpleasant,  and  the  former 
drug  taken  up.  Alcoholics  and  persons  trying  to 
escape  from  the  opium  habit  are  the  most  common 
victims. 

In  one  instance  reported  antipyrin  was  taken  for 
two  years ;  then  the  patient  died  of  pneumonia.  It 
was  found  that  he  had  used  large  quantities  daily  of 
this  drug.  The  only  symptoms  manifest  were  great 
irritabiHty  associated  with  prolonged  periods  of 
stupor  and  general  decline  of  health  and  vigor. 

Jamaica  ginger  is  another  form  of  alcoholic  addic- 


Jamaica  Ginger  333 

tion  which  in  some  sections  is  used  very  largely.  It 
is  usually  a  form  of  cheap  alcohol  mixed  with  ginger, 
the  latter  being  only  a  mild  stimulant  and  irritant, 
the  former  having  the  same  effect  as  other  spirits. 

Several  cases  have  been  reported  in  which  its  use 
was  decided  to  be  harmless  and  in  no  way  responsi- 
ble for  the  mental  disturbances  and  irregular  con- 
duct following.  This  is  incorrect.  The  use  of 
Jamaica  ginger  containing  from  10  to  40  per  cent,  of 
alcohol  is  precisely  like  that  of  other  alcohols,  and 
cases  of  this  addiction  should  be  treated  in  the  same 
way,  and  are  always  followed  by  the  same  class  of 
symptoms,  though  less  prominent.  The  use  of 
Jamaica  ginger  is  not  always  safe,  and,  particularly 
where  taken  continuously,  it  is  often  an  addiction 
perilous  to  the  user. 

Several  cases  are  reported  where  the  question  arose 
of  how  far  the  use  of  Jamaica  ginger  would  impair 
the  ability  of  the  patient  to  make  a  will  or  contract. 

In  one  instance  a  clergyman  sued  for  slander, 
claiming  that  the  term  "drunkard"  applied  to  him 
because  he  had  used  large  quantities  of  Jamaica 
ginger  was  wrong,  and  libelous.  In  the  trial  some 
very  curious  testimony  was  offered.  Two  physicians 
swore  that  Jamaica  ginger  could  not  produce  ine- 
briety and  that  no  one  coujd  become  intoxicated  from 
it.  The  defense  showed  that  the  tincture  of  Jamaica 
ginger  was  an  alcoholic  drink,  and  had  been  declared 


334  Morphinism 

by  the  courts  in  several  cases  to  be  an  intoxicant. 
The  late  Dr.  Day  swore  that  he  had  seen  many  cases 
fully  intoxicated  on  this  preparation  alone;  that 
some  of  these  cases  had  been  brought  to  his  institu- 
tion in  both  the  irritant  and  narcotic  stage,  while 
protesting  loudly  that  they  never  used  spirits,  and 
that  their  mental  trouble  was  owing  to  other  causes. 
This  case  ended  in  no  cause  of  action,  and  the  fact 
was  established  that  the  tincture  of  Jamaica  ginger 
was  an  alcoholic  and  intoxicant. 

The  increasing  demand  for  ginger  extracts,  to  be 
used  in  drinks  is  a  very  significant  hint  of  a  new 
phase  of  the  morbid  drink  impulses  of  the  age. 
There  are  several  large  establishments  where  ginger 
extracts  are  prepared  and  advertised  as  preventive 
medicines  for  the  diseases  of  various  seasons.  The 
quality  of  alcohol  used  is  usually  the  poorest,  and 
there  is  every  reason  to  believe,  owing  to  its  cheap- 
ness, that  wood  alcohol  is  often  used. 

Several  authors  have  asserted  that  the  excessive 
use  of  these  extracts  produces  a  distinct  form  of  in- 
toxication, marked  by  stupor  and  melancholia.  In 
some  instances  seen  by  the  writer  great  nutrient  dis- 
turbances and  inanition  were  present.  The  intoxi- 
cation was  less  maniacal,  and  there  was  greater 
depression. 

Many  compounds  are  flavored  with  other  sub- 
stances and  advertised  as  nerve  tonics.     It  is  quite 


Cologne  Narcosis  335 

evident  that  these  extracts  are  used  by  many- 
people  in  the  place  of  alcohol  for  its  effects  and  with- 
out the  odium  which  attaches  to  any  one  who  uses 
spirits  freely. 

A  man  recently  died  from  some  unknown  disease, 
and  among  his  effects  were  found  large  numbers  of 
Jamaica  ginger  bottles.  It  was  evident  that  he  was 
a  secret  drinker,  and  had  used  this  extract  in  pre- 
ference to  other  alcoholic  drinks.  The  symptoms 
before  his  death  were  not  recognized,  and  were  sup- 
posed to  result  from  some  mental  disturbance  and 
organic  disease. 

Another  form  of  addiction  has  been  noted  and  de- 
scribed at  some  length  by  several  writers  as  Cologne 
narcosis.  In  this  addiction  the  narcotic  action  is 
simply  that  of  alcohol,  which  is  in  most  cases  of  an 
inferior  kind,  concealed  by  the  flavoring  qualities  of 
cologne.  It  is  probable  that  the  odor  is  quite  as 
much  a  fascination  as  that  of  the  spirits. 

The  symptoms  and  conditions  are  those  of  exhilar- 
ation, extending  to  deHrium ;  then  depression,  sleep, 
and,  melancholia.  Obscure  and  complex  nerve 
disorders  associated  with  these  cases  readily  disap- 
pear with  the  removal  of  the  cause. 

These  are  all  alcoholic  cases  in  which  complex 
nutrient  degenerations  and  nervous  derangements 
are  sure  to  follow.  Delirium  and  delusions  are  also 
common,  but  not  distinctive. 


33^  Morphinism 

These  odoriferous  spirit  compounds  are  always 
dangerous,  whether  used  externally  or  internally  by 
drug  neurotics.  When  a  person  insists  on  surround- 
ing himself  with  pungent  odors,  there  is  always  a 
suspicion  that  they  are  taken  to  conceal  the  internal 
use  of  drugs,  and  also  for  some  odor  fascination 
which  exists. 

Gelsemium  is  another  drug  which  after  its  use  a 
short  time  becomes  a  pleasing  narcotic  and  is  con- 
tinued. In  the  cases  so  far  reported  paleness, 
emaciation,  and  listlessness  are  the  common  symp- 
toms. The  mind  is  troubled  with  hallucinations, 
which,  while  seemingly  real,  are  corrected  after  a 
while.  The  vision  is  always  disturbed.  Mental 
failure  without  any  lesion  follows,  and  the  patient 
sinks  into  a  kind  of  premature  senile  decay.  The 
possibility  of  detection  is  very  great,  and  such  cases 
can  rarely  be  concealed  long. 

Profound  narcosis  has  followed  its  use  in  certain 
persons,  and  care  should  be  exercised  in  giving  it. 
Two  cases  are  reported  of  death  following  its  use 
where  it  was  given  in  increasing  doses  until  sleep 
came.  An  addiction  may  follow  its  long  use,  but 
this  can  be  anticipated  in  most  cases. 

Sulfonal  has  become  a  modem  addiction.  Sev- 
eral cases  have  been  reported  of  persons  who  have 
taken  from  two  to  three  drams  per  diem  of  this  drug. 
After  a  time  it  ceases  to  produce  prolonged  sleep. 


Paraldehyd — Extract  of  Lavender       337 

In  the  cases  reported  excessive  inanition  and  col- 
lapse have  taken  place. 

The  poison  effect  seems  to  fall  most  heavily  on  the 
heart,  with  symptoms  of  cardiac  failure,  shortness 
and  slowing  up  of  the  beat,  also  mental  symptoms 
of  alarm  and  distress  from  the  least  exertion ;  these 
are  the  common  symptoms.  When  using  this  drug, 
watch  the  action  of  the  heart,  and  with  the  first  sign 
of  depression,  stop  it. 

Paraldehyd  has  been  used  by  some  neurotics  con- 
tinuously for  its  effects,  and  it  may  be  called  one  of 
the  modem  addictions.  Excessive  prostration  and 
a  low  form  of  muttering  delirium  are  the  common 
symptoms. 

The  powerful  odor  of  the  drug  prevents  it  from 
being  concealed,  and  its  rapid  exhalation  by  the 
breath  indicates  the  form  of  drug  taken.  The  re- 
moval of  the  drug  is  very  qiiickly  followed  by  a 
change  of  all  the  symptoms,  and  the  early  causes  are 
then  uncovered  for  treatment. 

Among  neurotics  it  should  always  be  taken  into 
consideration  that  the  use  of  paraldehyd  may  result 
in  an  addiction  should  the  drug  be  found  agreeable. 
A  few  cases  have  been  reported,  but  they  differ  little 
from  the  ordinary  alcohoUc,  and  are  so  apparent  in 
the  odor  of  the  breath  as  to  be  unmistakable. 

Extract  of  lavender  is  another  drug  that  has  been 
used  quite  freely  for  its  narcotic  properties,  depend- 


338  Morphinism 

ing,  of  course,  upon  the  spirits  which  it  contains,  A 
New  York  house  for  several  years  prepared  large 
quantities  of  this  extract  on  special  orders.  It  was 
found  that  it  went  to  the  homes  of  secret  drinkers, 
particularly  women  in  the  better  circles,  and  was 
used  the  same  as  any  other  spirit. 

Extracts  frequently  contain  from  lo  to  30  per 
cent,  of  alcohol,  and  are  literally  alcoholic  drinks. 
Other  extracts,  of  wintergreen,  peppermint,  and  other 
flavoring  oils,  have  a  fitful  sale  in  different  parts  of 
the  country,  and  are  frequently  replaced  by  stronger 
alcohols. 

In  some  parts  of  England  capsicum  extracts  are 
very  popular,  and  become  a  daily  addiction  among 
those  who  have  formerly  used  spirits.  There  is 
probably  in  these  cases  more  nutrient  disturbances 
than  in  others. 

A  proprietary  liniment  containing  capsicum, 
opium,  camphor,  benzoin,  guaiac,  and  alcohol,  called 
a  "  pain  killer,"  has  been  followed  by  several  cases  of 
addiction.  The  symptoms  were  those  of  profound 
anemia  and  mental  depression,  ending  in  death  from 
acute  nephritis. 

In  all  probability  many  proprietary  medicines 
containing  alcohol  and  opium  are  the  active  and  ex- 
citing causes  of  neuroses  which  are  not  recognized, 
and  end  fatally  in  some  acute  disease. 


CHAPTER  XVIII 
SOME  CONCLUSIONS 

Different  Drug  Addictions.  Narcomaniacs  Common.  Medico- 
legal Interest.  Public  Treatment.  Private  Treatment.  Colony 
Settlements. 

These  are  some  of  the  most  prominent  and  dan- 
gerous of  the  many  drugs  which  are  used  for  their 
narcotic  or  other  effects  until  their  use  becomes  a 
veritable  mania. 

In  malarious  countries  the  use  of  quinin  often  be- 
comes an  addiction,  which  is  continued  until  death 
or  some  intervening  influence  stops  its  use.  The 
anemia  and  general  degeneration  following  its  con- 
tinuous addiction  are  attributed  to  other  than  the 
real  cause.  Spirits  are  sometimes  associated  with 
it  to  overcome  the  exhaustion,  and  the  narcomania 
of  quinin  and  whisky  is  very  common  in  certain 
sections. 

Morphinism  not  infrequently  follows  this  addic- 
tion, and  cases  of  an  early  history  of  this  quinin 
addiction  are  found  to  be  largely  incurable.  In  cer- 
tain sections  of  the  country  where  botanic  treatment 
has  been  prominent  for  a  long  time  drug-manias  are 
also  more  or  less  common.     They  begin  frequently 

339 


340  Morphinism 

among  persons  who  are  convinced  that  the  vegetable 
world  contains  remedies  for  the  cure  of  all  diseases 
and  disorders.  In  their  search  for  these  remedies 
they  find  some  attractive  drug,  and  ever  after  con- 
tinue its  use. 

Most  of  these  drug  manias  do  not  show  disturb- 
ances of  the  senses  and  brain  in  the  early  stages, 
hence  the  injury  is  concealed  for  a  long  time.  A 
number  of  drug  manias  have  been  reported  where 
preparations  of  iron  have  been  taken  daily  for  a  long 
time  on  the  supposition  that  it  was  needed  to  sustain 
the  brain  and  nervous  system.  Chlorid  of  sodium  is 
another  drug  which  has  been  used  for  the  same  pur- 
pose. In  one  instance  a  person  who  had  taken  it  for 
years  was  suddenly  deprived  of  its  use  by  his  family. 
Delirium  followed,  and  he  was  taken  to  an  asylum 
for  treatment. 

Other  equally  strange  and  pecuHar  drugs  have 
been  used  continuously  until  veritable  manias  fol- 
lowed. Without  doubt,  a  large  proportion  of  the 
consumers  of  proprietary  drugs  are  simply  narco- 
maniacs in  the  early  stages.  Later  they  abandon 
these  drugs  for  morphin,  spirits,  and  other  narcotics. 

Recent  researches  as  to  the  effects  of  alcohol  on 
the  brain  and  nervous  system  indicate  that  it  is  an 
anesthetic  and  paralyzant.  Its  supposed  stimulant 
action  is  simply  a  stage  of  irritation  of  brief  duration, 
quickly   followed   by  an  esthesia   and   depression; 


Some  Conclusions  341 

hence  the  use  of  alcohol  is  a  narcomania  of  the  same 
class  as  that  of  opium.  The  alcoholic  drug-taker  is 
seldom  concealed,  and  goes  about  boldly,  boasting 
of  his  addiction  and  defending  its  use.  The  narco- 
maniacs using  other  drugs  are  always  more  or  less 
secretive,  and  the  symptoms  and  progress  of  the  dis- 
ease are  complex  and  confusing  to  the  ordinary 
observer. 

Medicolegally,  the  drug-taker  has  come  into  great 
prominence  in  many  unexpected  ways.  Thus,  wills 
are  found  to  date  from  some  disturbed  condition  of 
the  mind,  when  evidently  under  the  influence  of  some 
narcotic  drug.  Contracts  which  have  been  disputed 
have  revealed  the  narcomania  of  the  maker,  which 
was  unsuspected  before. 

In  a  case  of  murder,  it  was  shown  that  the  assailant 
was  delirious  from  large  doses  of  quinin  taken  before 
the  act.  Often  assaults  are  clearly  traced  to  the 
drug-taking  of  the  assailant.  These  cases  are  evi- 
dently increasing  every  year. 

A  practical  question  occurs :  What  can  be  done  in 
the  way  of  prevention  and  cure  ?  and  how  is  it  pos- 
sible to  distinguish  the  causes  and  discriminate  in  the 
early  stages  of  these  manias  and  possibly  avert  the 
dangers  which  are  certain  to  follow? 

In  many  of  these  addictions  the  chronicity  of  the 
case  is  such  that  efforts  to  cure  are  frequently  fruit- 
less, no  matter  what  form  of  treatment  is  used.     The 


342  Morphinism 

alternations  of  sanity  and  insanity  give  encourage- 
ment to  the  theory  of  vice  and  the  possibility  of  suc- 
cessful treatment  by  fear  and  punishment,  but  liter- 
ally this  has  been  found  to  increase  the  disorder  and 
make  the  person  more  helpless.  Evidently  the  time 
has  come  for  a  fuller  recognition  of  these  psychoses 
and  insanities  and  for  a  demand  that  they  should 
come  under  observation  and  treatment. 

In  the  near  future  all  such  persons  will  be  sent 
into  detention  hospitals  where  they  may  be  treated 
and  come  under  scientific  observation.  Here 
the  drug  may  be  removed  and  a  degree  of  health 
restored,  and  the  history  of  the  case  be  studied 
until  its  progress  and  characteristics  are  known. 
Later,  should  the  person  prove  to  be  a  chronic  case, 
he  should  be  placed  in  a  farm  colony  for  more  per- 
manent restraint  and  treatment.  These  colonies 
should  be  semi-military  cottage  hospitals  scattered 
through  the  country,  with  accommodations  for  from 
fifty  to  a  hundred  patients,  where  occupation  is 
made  a  large  part  of  everyday  treatment.  Re- 
straint and  medicinal  and  hygienic  care  should 
constitute  the  principal  methods  of  treatment. 
Here  suitable  surroundings,  with  exact,  uniform 
conditions  of  life,  continued  for  long  periods,  would 
most  likely  restore  many  to  health  and  useful  citizen- 
ship. Others  would  be  protected,  housed,  and  made 
self-supporting. 


Some  Conclusions  343 

In  the  detention  hospital  the  acute  cases,  after 
withdrawal  of  the  drug,  could  go  out  on  parole  under 
observation,  with  liability  to  be  returned  any  moment 
from  relapse.  There  these  cases  could  be  regulated 
and  cared  for,  and  the  possibility  of  subsequent  home 
treatment  by  the  family  physician  could  be  deter- 
mined and  carried  out  most  practically. 

These  are  mere  outlines  of  general  plans  of  treat- 
ment, which  are  not  only  practical,  but  whose  success 
is  assured  in  many  ways.  All  such  hospitals,  both 
public  and  private,  should  be  legalized  and  have  full 
power  of  restraint  of  each  patient.  The  very  wealthy 
cases  could  find  private  treatment  in  small  homes, 
and  the  middle  classes  would  go  to  the  detention 
hospital  for  temporary  treatment,  then  go  back  to 
the  family  physician,  while  the  large  armies  of  chronic 
incurable  cases  wotdd,  after  a  period  of  observation 
at  the  detention  hospital,  go  into  farm  colonies  and 
remain  during  life. 

The  physical  character  of  morphinism  and  other 
narcomanias  is  beyond  all  question.  Their  cure  and 
prevention  are  equally  certain  in  a  majority  of  cases 
with  adequate  treatment,  and  are  only  limited  by 
ignorance  of  the  laws  of  causation  and  the  growth 
and  development  of  the  disease.  There  can  be  no 
doubt  that  these  cases  will  be  successfully  treated 
in  the  near  future  by  the  family  physician,  the  de- 


344  Morphinism 

tention  hospital,  and  the  farm  colony,  and  the  family- 
physician  again. 

This  new  field  of  psychopathy  is  open  for  settlers. 
We  are  on  its  borders,  and  the  ever- widening  vista 
and  promise  of  permanent  cure  for  many  who  are 
helpless  should  arouse  the  keenest  interest  to  go 
forward  and  utilize  the  practical  facts  at  our  com- 
mand. 


INDEX 


Addiction     to     opium     first 
pointed  out,  26 

in  France,  29 

in  Germany,  29 
Alcohol  compared  with  opium, 

134 
and  cocain,  283 
dangerous  when  used  with 

chloroform,  341 
should  not  be  used  in  the 
treatment    of    morphinism, 
181 
Alcoholic   gastritis   associated 
with  caffeinism,  309 
inebriates     compared    with 
morphinists,  259 
effects  of  morphin  on,  73 
resemblance     to     opium- 
smokers,  213 
Alcoholism     preceding     mor- 

{jhinism,  95 
butt  first  called  attention  to 
morphin  craving,  27 
Alt  on  the  physiologic  action 

of  opitun,  222 
Amblyopia  from  tobacco,  317, 

319 
Anesthesia  in  morphimsm,  116 
Animals,  effects  of  opitmi  on, 

208 
Antidote  to  morphin,  189 
^tipyrin  addiction,  332 

general  symptoms,  332 
Appearance     in     morphinism, 

136 
Appendicitis  #following    mor- 
phinism, 85 
Appetite  in  morphinism,  134 
Arabian    physiaans,     use     of 
opivmi  by,  30 


Army  life,  use  of  opium  in,  76 
Arsenic  addiction,  327 

associated  with  other  dis- 
eases, 328 
first  used  in  Austria,  327 
general  symptoms  of  addic- 
tion to,  327 
secret  use  of,  329 
tolerance  of,  328 
treatment  of  the  addiction, 

329  ,     , 

Assaults,    crimmal,    by    mor- 
phinists, 226 
Asylums,  special  and  private, 

surroundings  of,  162 

Baths  in  treatment  of   mor- 
phinism, 174 

electric,  175 

shower,  178 

Tvu-kish,  176 

warm,  176 
Berillon  on  the  treatment  of 

morphinism,  183 
Botanic   remedies  render  the 

treatment     of    morphinism 

difficult,  340 
Bronchitis  in  morphinism,  186 

Capsicum  extracts,  338 

in  proprietary  preparations, 

338 
symptoms  from  the  abuse  of, 

338 
used  with  other  drugs,  338 
Cerebrasthenia  an  early  cause 

of  morphinism,  33 
China,  opium-taking  in,  203 


345 


346 


Index 


Chloral,  doses  of,  289 

sale  of,  in  drug-stores,  292 
used  as  "knock-out"  drops, 

289 
Chloralism,  287 

as  a  result  of  insomnia,  287 
degrees  of  responsibility  in, 

292 
delirium  in,  288 
delusions  in,  291 
in  women,  287 
mental  symptoms,  291 
mistaken  for  organic  disease, 

290 
not  easily  recognized,  292 
prevalence  among  the  higher 

classes,  288 
treatment,  290 
withdrawal  symptoms,  291 
Chloroform  addiction,  increase 

of,  293 
alcohol  dangerous  when  used 

with,  300 
as   a   cause   of   mania   and 

melancholia,  296 
as  a  cause  of  neuritis,  295 
as  a  cause  of  sudden  death 

from  syncope,  295 
associated  with  the  opium 

habit,  295 
effect  on  the  stomach,  294 
fascination  for,  295 
habit    during    middle    life, 

300 
periodic  takers,  294 
recovery  from  the  addiction, 

299 
responsibility  of  the  taker, 

300 
tetanic  spasms  from,  301 
treatment  of  the  addiction, 

297 
used  for  insomnia,  293 
Cocain,  action  of,  273 

affecting  the  judgment,  281 
as  a  cause  of  hallucinations, 

282 
as  a  cause  of  insomnia,  282 
as  a  cause  of  mental  exalta- 
tion, 280 
compared  with  alcohol  and 

opium,  283 


Cocain,  different   varieties  of 
takers,  275 
effects  on  the  brain,  277 
on  the  emotions,  279 
on  the  heart,  278 
on  the  respiration,  277 
on  the  temperature,  277 
on  the  voice,  279 
history   of   the   use   of   the 

drug,  270 
indiscriminate  sale  of,  286 
its  use  by  the  needle,  271 
its  use  increasing,  272,  285 
large     number     of    victims 
among  physicians  and  pro- 
fessional men,  286 
methods  of  using,  274 
periodic  takers,  275 
physiologic  action  of,  284 
sold  as  a  poptdar  remedy, 

273 

sold  by  peddlers,  272 

treatment  of  the  addiction, 
284 
Coffee,  acute  and  chronic  con- 
ditions of  caffeinism,  307 

causing  insomnia  and  nerv- 
ousness, 303 

causing  intoxication,  303 

delirium  from,  305 

delusions  from,  303 

diagnosis  by  exclusion,  306 

exaltation  from  use  of,  310 

general  pathology,  308 

impairment    of    the    mind 
from,  304 

its  effect  on  morphin  cases, 
135 

mental  incapacity  from,  304 

treatment  of  the  addiction, 
310 

widespread  use  of,  303 
Cologne  associated  with  alco- 
hol addiction,  335 

attraction    from    its    odor, 
336 

causing    delusions    and    de- 
lirium, 335 

general  symptoms  of,  335 

narcosis  from,  335 
Confessions     of     morphinists, 

224 


Index 


347 


Criminal  acts  of  morphinists, 

235 
use  of  opium,  266,  268 


Danger  as  a  result  of  opium- 
taking,  206 
consciousness    of,    in    mor- 
phinism, 100 
Death  from  morphinism,  156 
unsuspected  in  morphinism, 
128 
Defects,    mental    and    other, 

from  morphinism,  64 
Degeneration  transmitted 

through  morphinism,  64 
Delirium  from  morphin,  98 
from  opium-smoking,  217 
Delusions  of  egotism  in  mor- 
phinism, 152 
of  honesty  in  morphinism, 

256 
of  personal  injvuy  in  mor- 
phinism, 131 
of  suspicion  in  morphinism, 
263 
De    Quincey    on    the    use    of 

opium,  33 
Dreams  from  use  of  morphin, 

98 
Duration  of  cases  of  morphin- 
ism, 129 


Egyptian  opium,  19 
Electricity  in  morphinism,  175 
Erotic  paroxysms  in  morphin- 
ism, 112 
Eroticism  in  morphinism,  239 
Ether  a  cheap  intoxicant,  322 
a  delirious  exhilarant,  323 
after-effects  of,  325 
anesthesia  from,  324 
complication      with      other 

drugs,  325 
concealed    in    other    drugs, 

325 
demand  for,  324 
fascination  of,  325 
inebriety,  322 

confined  to  certain  loca- 
tions, 322 


Ether,    special    symptoms   of 
the  addiction,  324 
the  habit  described  by  Drs. 

Kerr  and  Hart,  323 
treatment  of  the  addiction, 
326 
Etiology  of  morphinism,  57 
Exhaustion     preceding     mor- 
phinism, 98 
Eye  symptoms  in  morphinism, 
134 


Faradism  in  morphinism,  187 
Farm  colonies  for  the  care  of 

opium  habituates,  342 
French  on  the  tobacco  addic- 
tions, 317 


Gelsemium    a   narcotic   little 
used,  336 
death  following  its  use,  336 
mental    impairment    from, 

336 
prominent  symptoms  of  ad- 
diction, 336 
Ginger,  Jamaica,  a  form  of  al- 
coholic addiction,  332 
cases     of     addiction     re- 
ported, 333 
differences  of  opinion  re- 
garding addiction,  334 
general  symptoms  of  the 

addiction,  334 
its  secret  use,  334 
medicolegal  problems  re- 
garding habit  of,  334 
Gynecologic  disorders  followed 
by  morphinism,  87 


Habituates,  those  who  use 
opium  in  the  United  States, 

29     .       . 

Hallucinations  m  morphinism, 
118 

Hamberger  on  stomach- wash- 
ing in  morphinism,  145 

Happell,  report  of  cases  of  de- 
fective children  of  morphin- 
taking  mothers,  61 


348 


Index 


Hashisch,  use  of,  in  India,  323 
Heredity  of  morphinism,  58 
Home  treatment  of  morphin- 
ism, 100 
Homer  describes  opium,  17 
Hospitals  for  the  detention  of 
opium  inebriates,  343 
for  the  treatment  of  opitun 
cases,  342 
Hughes,    description   of  mor- 

phin-taking  neurotics,  80 
Hyperesthesia  in  morphinism, 

117 
Hypodermic,  first  use  of  opitmi, 

Insanity,  delusions  of,  152 

symptoms  of,  112 
Insomnia  following  use  of  mor- 
phin,  115 
from  coffee,  303 
periodicity  of,  in  morphin- 
ism, 181 
Irresponsibility,  reasons  for,  in 
morphinism,  232 


Jones,  Macnaughton,  on  the 
danger  from  the  use  of  mor- 
phin,  90 


Kleptomania  a  symptom   of 

morphinism,  no 
Knock-out  drops,  289 


Lavender  a  secret  addiction, 

338  . 
alcoholic  extract  of,  338 
attraction  of  highly  flavored 
extract  of,  338 
Leigh,  essay  on  opium,  20 
Lentz  on  the  mental  changes 

in  morphinism,  107 
Lett  on  the  detection  of  mor- 

phin  addiction,  143 
Levenstein,     monograph     on 
morphinism,  27 
on  the  plan  of  treatment  in 
morpninism,  166 


"  London  Lancet "  first  pointed 
out  the  dangers  of  opium 
addiction,  26 


Mania  for  iron,  340 
for  sodium,  340 
of   deception  in  opium  ha- 
bituates, 258 
of  religion  in  opitun  habitu- 
ates, 261 
Mattison  on  opivun  addiction, 

28 
Mental  disturbances  in  opium 

habituates,  199 
Morphin  and  its  alkaloids,  22 
as  a  cause  of  insomnia,  115 
criminal  acts  of  takers,  235 
how  the   addiction  is  con- 
sidered, 76 
its  secret  use,  10 1 
its    use    in    surgical    opera- 
tions, 84 
mental  changes  from  its  use, 

108 
narcotism  from,  49 
poison  symptoms  from  the 

early  use,  48 
poisonous  effect  of ,  7 1 

on  the  alcoholic  inebri- 
ate, 73 
prevalence      of      addiction 
among  physicians,  30 
among  the  lower  classes, 

30 
in     France     and     Ger- 
many, 29 
quantity  used  in  the  United 

States,  29 
sold  by  country  peddlers,  39 
substitutes  for,  159 
tests  for,  147 
the  ethical  changes  from  its 

use,  109 
used  on  the  frontier,  39 
Morphinism  a  modem  disease, 

33 
among  brain-workers,  44 
baths  in  treatment  of,  174 
degrees  of  curability,  339 
divided   into   three    stages, 

49 


Index 


349 


Morphinism,    double    person- 
ality in,  248 
due  to  civilization,  32 
electricity  in  treatment  of, 

175 

etiology  of,  57 

faulty  mind  in,  223 

first  stage  of,  50 

hallucinations  in,  118 

home  treatment  of,  191 

injections  of  water  in  the 
treatment,  34 

its  influence  on  neiu"otic 
families,  69 

marasmus  as  a  termination 
of,  128 

methods  of  treatment,  154 

neurotic  tendency  in,  59 

on  the  increase  from  the  use 
of  the  needle,  38 

second  stage  of,  50 

study  of  the  cause  from  the 
physical  standpoint,  57 

study  of  the  heredity  of,  58 

the  term  described,  42 

third  stage  of,  52 

transmission  to  children  of, 
60 

transmitted  to  child  from 
mother  using  opium  dur- 
ing pregnancy,  62 

treatment  of,  in  asyltuns,  153 

vmknown  cases,  31 

varieties  of,  172 
Morphinists  as  swindlers,  252 

as  witnesses,  229 

description  of,  47 

examples  of  mental  condi- 
tion, 269 

morals  of,  226 

unreliability  of,  224 
Morphinomania,       description 
of,  42 

responsibility  of  victims, 
228,  230 


Narcotics    in    treatment    of 

morphinism,  157 
Nervous     system,     effects     of 

morphinism  on,  63 


Neurasthenia  an   early   cause 

of  morphinism,  33 
Neuritis,  effect  of  opium  on,  73 
Neurotic  changes  in  inherited 
cases,  65 
families,  effect  of  morphin- 
ism on,  69 


Opium  addiction  in  army  life, 

76 
amount  consumed  by  takers, 

302 
caution  in  its  administration 

to  the  aged,  207 
dangers  of  the  addiction,  206 
compared  with  alcohol  and 

cocain,  283 
delirium  resulting  from  the 

addiction,  217 
delusions  resvilting  from  the 

addiction,  266 
first  use  of,  19 
its  effect  on  animals,  208 
its  effect  on  nevirotics,  73 
its  effect  on  the  stomach,  160 
its  effects  first  described,  20 
its  use  by  morphin-takers, 

mental       disturbances      m 

habituates,   199 
pathologic  changes  from  the 

addiction,  207 
prevalence  of  the  addiction, 

197 
smoking  of,  209 

in  fashionable  circles,  211 

prevalent   in    New   York 
city,  216 

prognosis  of,  215 

treatment  of,  214 
symptoms  of  the  addiction, 

198 
symptoms    of    withdrawal, 

200 
the  addiction  in  China,  203 
the  English  Commission  on, 

202 
treatment  of  the  addiction, 

201 
used  for  criminal  piirposes, 

268 


350 


Index 


Paraldehyd  addiction,  337 
powerful  odor  of,  337 
resemblance  to  alcoholic  ad- 
diction, 337 

Paralysis,     general,     resulting 
from  morphinism,  113 
of  will,  227 

Paralytics,  moral,  185 

Parrish  on  opium  addiction,  28 

Personality,  double,  248 

Physical     degeneration     from 
opium,  66 

Physicians  as  morphin-takers, 

30 
prescribe  morphin,  32 
Poisonous  effect  of  morphin. 

Poppy  first  mentioned,  17 
Pravaz    introduced    into    the 

French  army  the  hypoder- 
mic syringe,  26 
Predispositions  to  the  opium 

addiction,  66 
Pregnancy,  use  of  opium  by 

the  mother  during  gestation 

as  a   cause   of  morphinism 

in  the  offspring,  63 
Price,  Joseph,  on  dangers  from 

the  use  of  opium,  88 
Prognosis  in  morphinism,  138 

in  opium-smokers,  215 
Proprietary  medicines  contain 

morphin,  32 
Prussia,  morphin  addiction  in, 

76 
Psychic  changes  from  the  use 
of  morphin,  66 

palsy,  250 

examples  of,  250 
Psychologic  impressions  from 

the  use  of  morphin,  96 
Psychoses  of  tea-drinkers,  314 
Psychotherapeutic    treatment 

for  morphinism,  183 

QuiNiN  addiction,  339 

associated  with  alcoholic 
excess,  339 

Recoveries,     sudden,     from 
morphinism,  137 


Reduction     of     morphin     by 
gradual  plan,  154,  156 
by  rapid  plan,  155 

Regnier  first  to  classify  mor- 
phinists, 28 

Responsibility  of  morphinists, 
228 

Restlessness  after  use  of  mor- 
phin, 67 

Restraint,  stimulating,  153 

Reynolds  on  tobacco,  318 

Roberts,  Sir  William,  on  the 
value  of  opium  alkaloids, 
202 

Rolland  on  the  first  use  of 
opium  paste,  and  also  the 
watery  solution,  21 


Savage,  description  of  chloro- 
form, 296 

Secret   drugs  in   morphinism, 
130 

Seguin,  discovery  of  the  alka- 
loid of  opium,  23 

Sensory   defects  in  morphin- 
ism,  106 

Sertumer  first  investigated  the 
nature  of  the  poppy,  23 

Shock,    psychic,    followed    by 
morphinism,  85,  93 

Skin,  changes  of,  in  morphin- 
ism, 136 

Sodium  mania,  340 

Specific  preparations  contain- 
ing morphin,  158 

Statistics  concerning  the  use 
of  morphin,  30 

Stimulation  from  morphin,  97 

Stomach,  effect  of  opium  on, 
160 
washing  out,  in  morphinism, 

145 
Study  of  morphinomania,  245 
Sugar  in  opium,  24 
Sulfonal  a  modem  addiction, 

amount  taken,  337 
its  action,  337 
symptoms  of,  337 
Svinstroke  as  a  cause  of  mor- 
phinism, 78 


Index 


351 


Surgery,  morphin  in,  84 
Swindling  by  morphinists,  252 
Symptoms  in  the  early  use  of 
morphin,  103 
of  morphin  withdrawal,  162 
of  opium  withdrawal,  200 
of  opium-taking,  197 
of    secret     morphin-taking, 

103 
of  withdrawal  in  chloralism, 

291 
imiformity  of,  133 


Taylor  first  used  morphin  by 
hypodermic  injection,  25 

Tauszk  on  caution  in  giving 
opiates  to  the  aged,  207 

Tea   addiction,   psychoses   of, 

314 
treatment  of,  314 
cigarettes  made  of,  314 
compared    with    caffein    in 

physiologic  action,  313 
essential  oils  of,  312 
inebriety,  311 

a  well-marked  disease,  311 
delusions  from,  311 
digestive         disturbances 

from,  312 
effects  on  the  brain-cen- 
ters from,  312 
general  symptoms,  311 
hallucinations  from,  311 
Wood's    experiments   with, 
312 
Tetanus    in    morphin    takers, 

40 
Tobacco  cigarettes,  dangers  of, 
318 
habit,  amblyopia  from,  317 
associated    with    alcohol, 

317 
description  by  Reynolds, 

318 
effect  on  the  mind,  320 
French  on  the  perils  of, 

317 


Tobacco     habit,     medicolegal 
problems  of,  320 
mental     impairment     of, 

ppison  symptoms  of,  315 
treatment  of,  320 
Trauma  as  a  cause  of  morphin- 
ism, 84 
Treatment  of  caffeinism,  310 
of  chloralism,  290 
of  cocainism,  284 
of  ether  inebriety,  325 
of  morphinism,  154 
at  home,  190 
by  elimination,  168 
Kellogg's  plan,  167 
success  of,  194 
of  opium  addiction,  201 
of  opitun-smoking,  214 
of  the  arsenic  addiction,  330 
Trional  addiction,  330 

disease  following  the  addic- 
tion, 332 
general  symptoms  of  addic- 
tion, 331 
not  a  safe  hypnotic,  330 


Varieties  of  morj)hinism,  172 
Voice,  changes  of,  in  morphin- 
ism, 136 


Water,  injections  of,  in  mor- 
phinism, 34 
Waugh's  antidote  to  morphin, 

189 
Wills  made  under  the  influence 

of  morphin,  225 
Witnesses,  morphinists  as,  229, 

241 
Women  more  susceptible  than 

men  to  morphinism,  88 
Wood,  injections  of  opium  into 

the  skin,  21 
Wood,  studies  of  tea  inebriety, 

31a 


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DAVIS'S  OBSTETRIC  NURSINQ. 

Obstetric  and  Gynecologic  Nursing.  By  EDWARD  P.  DAVIS,  A.  M.,  M.  D., 
Professor  of  Obstetrics  in  Jefferson  Medical  College  and  the  Philadelphia 
Polyclinic ;  Obstetrician  and  Gynecologist  to  the  Philadelphia  Hospital. 
i2mo  volume  of  400  pages,  fully  Illustrated.     Crushed  buckram,  ^1.75  net. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.    Third  Edi- 
tion, Revised. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G.  E. 
DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical 
College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  696  pages ; 
256  fine  illustrations  and  2  chromo-lithographic  plates.  Cloth,  $4.00  net ; 
Sheep  or  Half  Morocco,  ^5.00  net. 

BORLAND'S  DICTIONARIES. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

DORLAND'S    OBSTETRICS.      Second    Edition,    Revised    and 
Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  NEWMAN  DORLAND,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania ;  Associate  in  Gyne- 
cology, Philadelphia  Polyclinic.  Octavo  volume  of  797  pages,  with  201 
illustrations.     Cloth,  $4.00  net. 

EICHHORST'S  PRACTICE  OF  MEDICINE. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  HERMAN  ElCHHORST, 
Professor  of  Special  Pathology  and  Therapeutics  and  Director  of  the  Medi- 
cal Clinic,  University  of  Zurich.  Translated  and  edited  by  Al'GUSTUS  A. 
ESHNER,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic, 
Two  royal  octavo  volumes,  600  pages  each,  150  illustrations.  Per  set: 
Cloth,  $6.00  net;  Sheep  or  Half  Morocco,  ;^7.5o  net. 

FRIEDRICH  AND  CURTIS  ON  THE  NOSE,  THROAT,  AND 
EAR. 

Rhinology,  Laryngology,  and  Otology,  and  their  Significance  in  General 
Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H.  HOLBROOK 
CtTRTlS,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose  and  Throat  Hos- 
pital.    Octavo,  348  pages.     Cloth,  $2.50  net. 

FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
M.  D.  v..  Assistant  in  Bacteriology  and  Veterinary  Science,  Sheffield  Scien- 
tific School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 

GALBRAITH  ON  THE  FOUR  EPOCHS  OF  WOMAN'S  LIFE. 

The  Four  Epochs  of  Woman's  Life.  A  Study  in  Hygiene.  By  ANNA  M, 
Galbraith,  M.  D.,  Author  of  "  Hygiene  and  Physical  Culture  for  Women"; 
Fellow  of  the  New  York  .Academy  of  Medicine,  etc.  With  an  Introductory 
Note  by  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University 
of  Pennsylvania.     i2mo  volume  of  200  pages.     Cloth,  $\.'iS  "c^- 


OF  W.  B.  SAUNDERS  &»  CO. 


OARRIGUES'    DISEASES    OF    WOMEN.    Third  Edition,   Re- 
vised. 

Diseases  of  Women.  By  Henry  J.  Garrigues,  A.  M.,  M.  D.,  Gynecolo- 
gist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New  York  City. 
Octavo,  756  pages,  with  367  engravings  and  colored  plates.  Cloth,  %i,.^o 
net ;  Sheep  or  Half  Morocco,  ^5.50  net. 

GORHAM'S  BACTERIOLOGY. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  GORHAM,  M.  A.,  Assistant 
Professor  in  Biology,  Brown  University.  i2mo  volume  of  192  pages,  97 
illustrations.     Cloth,  ^^1.25  net. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  GEORGE  M.  GOULD,  M.  D., 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  and  ex- 
traordinary cases  and  of  the  most  striking  instances  of  abnormality  in  all 
branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive  research  of 
medical  literature  from  its  origin  to  the  present  day,  abstracted,  classified, 
annotated,  and  indexed.  Handsome  octavo  volume  of  968  pages ;  295  en- 
gravings and  12  full-page  plates.  Popular  Edition.  Cloth,  $3.00  net ;  Sheeo 
or  Half  Morocco,  $4.00  net. 

GRADLE  ON  THE  NOSE,  THROAT,  AND  EAR. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gradle,  M.D..  Pro- 
fessor of  Ophthalmology  and  Otology,  Northwestern  University  Medical 
School,  Chicago.     Octavo,  500  pages,  illustrated.     Cloth,  ^.00  net. 

GRAFSTROM'S  MECHANO-THERAPY. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
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GRIFFITH  ON  THE  BABY.    Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  GRIFFITH,  M.  D.,  Clinical  Pro- 
fessor of  Diseases  of  Children,  University  of  Pennsylvania  ;  Physician  to  the 
Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages,  67  illustrations 
and  5  plates.     Cloth,  $1.50  net. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  GRIFFITH,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania.  25 
charts  in  each  pad.     Per  pad,  50  cts.  net. 

HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  Health.  By  Mr.s.  Ernest  Hart,  formerly  Student 
of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School  of  Medicine 
for  Women  ;  with  an  Introduction  by  Sir  Henry  Thomi-son,  F".  R.  C.  S., 
M.  D.,  London.     220  pages.     Cloth,  $1.50  net. 

HAYNES'  ANATOMY. 

A  Manual  of  .Vnatomy.  By  IRVING  S.  Haynes,  M.  D.,  Professor  of  Prac- 
tical Anatomy  in  Cornell  University  Medical  College.  680  pages ;  42  dia- 
grams and  134  full-page  half-tone  illustrations  from  original  photographs  of 
the  author's  dissections.     Cloth,  JU1.50  net. 


MEDICAL   PUBLICATIONS 


HEISLER'S  EMBRYOLOGY.     Second  Edition,  Revised. 

A  Text-Book  of  P:mbryology.  By  John  C.  Hkisler,  M.  D.,  Professor  of 
Anatomy,  Medico-Chirurgical  College,  Philadelphia.  "  Octavo  volume  of  405 
pages,  handsomely  illustrated.     Cloth,  ^^2.50  net. 

HIRST'S  OBSTETRICS.    Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  BARTON  CooKE  HlRST,  M.D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume  of 
873  pages,  704  illustrations,  36  of  them  in  colors.  Cloth,  ^5.00  net ;  Sheep 
or  Half  Morocco,  %b.oo  net. 

HYDE  &  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES.    2d  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  N'evins  Hyde,  M.  D.,  Pro- 
fessor of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and  FRANK  H. 
Montgomery,  M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary,  and 
Venereal  Diseases  in  Rush  Medical  College,  Chicago,  111.  Octavo,  594 
pages,  profusely  illustrated.     Cloth,  $4.00  net. 

INTERNATIONAL  TEXT-BOOK  OF  SURGERY.  Two  Volumes. 

By  American  and  British  Authors.  Edited  by  J.  COLLINS  Warren,  M.  D., 
LL.  D.,  F.  R.C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School, 
Boston  ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer  on  Practical 
Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School,  London,  Eng.  Vol.  L  General  Surgery. — Handsome  octavo,  947 
pages,  with  458  beautiful  illustrations  and  9  lithographic  plates.  Vol.  IL 
Special  or  Rcgioniil  Surgery. — Handsome  octavo,  1072  pages,  with  471 
.beautiful  illustrations  and  8  lithographic  plates.  Prices  per  volume : 
Cloth,  ^5.00  net ;  Sheep  or  Half  Morocco,  ;g6.oo  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The 
clinician  and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a 
satisfaction  to  the  editors  as  it  is  a  gratification  to  the  conscientious  reader." — Annals  0/ 
Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has 
very  many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different 
authors  is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor 
of  each  writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the 
technique  of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up 
to  date  in  a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional 
parts  of  the  body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which 
the  reader  may  not  learn  something  new." — Medical  Record,  New  York. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Disea.ses  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and  Col- 
lege for  Graduates  in  Medicine.  i2mo,  volume  of  535  pages,  with  178  illus- 
trations, mostly  from  drawings  by  the  author.     Cloth,  J2.50  net. 

KEATING'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  JOHN  M.  Keating,  M.  D.,  Fellow 
of  the  College  of  Physicians  of  Philadelphia ;  Ex-President  of  the  Association 
of  Life  Insurance  Medical  Directors.  Royal  octavo,  211  pages.  With 
numerous  illustrations.     Cloth,  $2.00  net. 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The  Surgical  Complications  and  Sequels  of  Typhoid  P^ever.  By  Wm.  W. 
Keen,  M.  D..  LL.D..  F,  R.  C.S.  (Hon.),  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.     Cloth,  $z-<x>  net. 


OF   W.  B.  SAUNDERS  6-    CO. 


KEEN'S  OPERATION  BLANK.    Second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required  in  Various 
Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.), 
Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.     Price  per  pad,  of  50  blanks,  50  cts.  net. 

KYLE  ON  THE  NOSE  AND  THROAT.    Second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Brade.n  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  646  pages  ;  over  150  illustrations  and  6  lithographic  plates. 
Cloth,  $4.00  net ;  Sheep  or  Half  Morocco,  $5.00  net. 

LAIN^'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  LAINfe,  M.  D.  Size  8  x  13}^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature,  with 
columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Re- 
marks, etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment  of 
Typhoid  Fever.     Price,  per  pad  of  25  charts,  50  cts.  net. 

LEVY,  KLEMPERER,  AND  ESHNER'S  CLINICAL  BACTERI- 
OLOGY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Professor 
in  the  University  of  Strasburg,  and  Dr.  Felix  Klemperer,  Privatdocent 
in  the  University  of  Strasburg.  Translated  and  edited  by  AUGUSTUS  A. 
Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic. 
Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.ya  net. 

LOCKWOOD'S    PRACTICE    OF    MEDICINE.    Second   Edition, 
Revised  and  Enlarged. 

A  Manual  of  the  Practice  of  Medicine.  By  GEORGE  RoE  LOCKWOOD, 
M.  D.,  Attending  Physician  to  Bellevue  Hospital,  New  York.  Octavo,  847 
pages,  fully  illustrated,  including  22  colored  plates.     Cloth,  $\Xio  net. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

MACDONALD'S  SURGICAL   DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  M.VCDONALD,  M.D.  Edin., 
F.  R.  C.S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery, 
Hamline  University.  Handsome  pjctavo,  800  pages,  fully  illustrated.  Cloth, 
S5.00  net;  Sheep  or  Half  Morocco,  56.00  net. 

MALLORY   AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 
Second  Edition,  Revised  and  Enlarged. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  .\natomy,  with  chapters  on  Post- 
Morfem  Technique  and  the  Performance  of  Autopsies.  By  FRANK  B. 
MaLLORY,  a.  M..  M.  D.,  .Assistant  Professor  of  Pathology,  Harvard  Uni- 
versity Medical  School,  Boston;  and  J  AMES  H.  WRIGHT,  A.M.,  M.D., 
Instructor  in  Pathology,  Hanard  University  Medical  School,  Boston. 
Octavo,  432  pages,  fully  illustrated.     Cloth,  $3.00  net. 


MEDICAL   PUBLICATIONS 


McCLELLAN'S  ANATOMY  IN  ITS  RELATION  TO  ART. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and  Muscles 
of  the  Human  Body,  with  Reference  to  their  Influence  upon  its  Actions 
and  External  Form.  By  Gkorge  McClkllan,  M.  D.,  Professor  of  Anat- 
omy, Pennsylvania  Academy  of  Fine  Arts.  Handsome  quarto,  9  by  11^ 
inches.  Illustrated  with  338  original  drawings  and  photographs,  260  pages 
of  text.     Dark  Blue  Vellum,  $10.00  net ;   Half  Russia,  ^$(12.00  net. 

McCLELLAN'S  REGIONAL  ANATOMY. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgery.  By  George 
McClellan,  M.  D.,  Professor  of  Anatomy  at  the  Pennsylvania  Academy 
of  Fine  Arts.  In  two  handsome  quarto  volumes,  884  pages  of  text,  and 
97  full-page  chromo-lithographic  plates,  reproducing  the  author's  original 
dissections.      Price:  Cloth,  $12.00  net ;   Half  Russia,  $15.00  net. 

McFARLAND'S    PATHOGENIC    BACTERIA.      Third    Edition, 
increased  in  size  by  over  100  Pages. 

Text-Book  upon  the  Pathogenic  Bacteria.  By  JOSEPH  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical  Col- 
lege, Phila.,  etc.     Octavo,  621  pages,  finely  illustrated.     Cloth,  $3.25  net. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  ARTHUR  V.  MEIGS,  M.  D.  Bound  in  limp 
cloth,  flush  edges,  25  cts.  net. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  IamI':s  E.  Moore,  M.  D.,  Professor 
of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  University  of 
Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume  of  356  pages, 
handsomely  illustrated.     Cloth,  $2.50  net. 

MORTEN'S  NURSES'  DICTIONARY. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Containing 
Definitions  of  the  Princip^il  Medical  and  Nursing  Terms  and  Abbreviations; 
of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations, 
Foods,  Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  By 
Ho.NNOR  Morten,  author  of"  How  to  Become  a  Nurse,"  etc.  i6mo,  140 
pages.     Cloth,  $1.00  net. 

NANCREDE'S  ANATOMY  AND  DISSECTION.    Fourth  Edition. 

Elssentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  CHARLES 
B.  NaNCREDE,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with  full-page 
hthographic  plates  in  colors  and  nearly  200  illustrations.  Extra  Cloth  (or 
Oilcloth  for  dissection-room),  $2.00  net. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surger>'.  By  Charles  B.  NANCREDE,  M.  D., 
LL.D,,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.     Cloth,  |!2.5o  net. 


OF  W.  B.  SAUNDERS  &r'  CO. 


NORRIS'S    SYLLABUS    OF    OBSTETRICS.     Third    Edition, 
Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department,  University  of 
Pennsylvania.  By  Richard  C.  Norris,  A.  M.,  M.  D.,  Instructor  in  Obstet- 
rics and  Lecturer  on  Clinical  and  Operative  Obstetrics,  University  of  Penn- 
sylvania.    Crown  octavo,  222  pages.     Cloth,  interleaved,  ^2.00  net. 

OGDEN  ON  THE  URINE. 

Clinical  E.xamination  of  the  Urine  and  Urinary  Diagnosis.  A  Clinical  Guide 
for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Surgery.  By  J. 
Bergen  Ogdf.N,  M.  D.,  lately  Instructor  in  Chemistry,  Harvard  Univer- 
sity Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  $3.00  net. 

PENROSE'S  DISEASES  OF  WOMEN.    Fourth  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  Universityof  Pennsylvania. 
Octavo  volume  of  538  pages,  handsomely  illustrated.     Cloth,  ;5S3.75  net. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  concerning 
the  Immediate  Treatment  of  Cases  of  Emergency.  By  WALTER  PYE, 
F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

PYLE'S  PERSONAL  HYGIENE. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic  Basis. 
Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the  Wills  Eye 
Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully  illustrated. 
Cloth,  $1.50  net. 

RAYMOND'S    PHYSIOLOGY.       Second   Edition,   Entirely    Re- 
written and  Greatly  Enlarged. 

A  Text-Book  of  Physiology.  By  Josei'H  H.  Raymond  AM.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  <  :  1;  Hospital, 
and  Director  of  Physiology  in  Hoagland  Laboratory,  New  \  ork.  Octavo, 
668  pages,  443  illustrations.     Cloth,  $3.50  net. 

SALINGER  AND  KALTEYER'S  MODERN  MEDICINE. 

.Modern  Medicine.  By  Julius  L.  Salinger,  M.D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College  ;  and  F.  J.  Kalteyer,  M.  D., 
Assistant  in  Clinical  Medicine,  Jefferson  Medical  College.  Handsome 
octavo,  801  pages,  illustrated.     Cloth,  §4.00  net. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundbv,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the  Roval 
Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason  College,  Bir- 
mingham, etc.  Octavo,  434  pages,  with  numerous  illustrations  and  4  colored 
plates.     Cloth,  3250 net. 

SAUNDERS'     MEDICAL     HAND-ATLASES.      See    pages     16 
and   17. 


MEDICAL   PUBLICATIONS 


SAUNDERS'  POCKET  MEDICAL  FORMULARY.     Sixth  Edi- 
tion, Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "  Essentials  of  Diseases  of 
Children"  ;  Member  of  Philadelphia  Pathological  Society.  Containing  1844 
formuliB  from  the  best-known  authorities.  With  an  Appendix  containing 
Posological  Table,  Formulae  and  Doses  for  Hypodermic  Medication, 
Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal 
Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs  used  in  Antiseptic 
Surgery,  Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer, 
Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc.  Flexible  morocco, 
with  side  index,  wallet,  and  flap.     $2.00  net. 

SAUNDERS'  QUESTION-COMPENDS.     See  pages  14  and  15. 
SCUDDER'S  FRACTURES.    Second  Edition,  Revised. 

The  Treatment  of  Fractures.  By  Chas  L.  Scuduer,  M.  D.,  Assistant  in 
Clinical  and  Operative  Surgery,  Harvard  University  Medical  School.  Oc- 
tavo, 433  pages,  with  nearly  600  original  illustrations.  Polished  Buckram, 
^4.50  net;   Half  Morocco,  $5.50  net. 

SENN'S  QENITO-URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By  NICH- 
OLAS Senn,  M.  D.,  Ph.  D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College,  Chicago.  Handsome  octavo 
volume  of  320  pages,  illustrated.     Cloth,  53-oo  net. 

SENN'S  PRACTICAL  SURGERY. 

Practical  Surgery.  By  NICHOLAS  SENN,  M.  D.,  Ph.D.,  LL.D.,  Professor 
of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical  College, 
Chicago.  Handsome  octavo  volume  of  1133  pages,  642  illustrations. 
Cloth,  ;j56.oo  net ;  Sheep  or  Half  Morocco,  ;J>7.oo  net.     By  Subscription. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  conformity 
with  "An  American  Text-Book  of  Surgery."  By  NICHOLAS  SENN,  M.  D., 
Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery. 
Rush  Medical  College,  Chicago.     Cloth,  ^1.50  net. 

SENN'S  TUMORS.    Second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  NICHOLAS  Senn,  M.  D., 
Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery, 
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illustrations,  includidg  12  full-page  plates  in  colors.  Cloth,  ;g5.oo  net ;  Sheep 
or  Half  Morocco,  $6.00  net. 

SOLLMANN'S  PHARMACOLOGY. 

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Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Univer- 
sity, Cleveland,  Ohio.  Royal  octavo  volume  of  894  pages,  fully  illustrated. 
Cloth,  ^3.75  net. 


C>    «'.   B.    SAUNDERS  ^^    CO.  1 3 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  LouiS  Starr, 
M.  D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of  Children.  " 
230  blanks  (pocket-book  size),  perforated  and  neatly  bound  in  flexible 
morocco.     $1.25  net. 

STENGEL'S  PATHOLOGY.  Third  Edition,  Thorouglily  Revised. 

A  Text-Book  of  Pathology.  By  ALFRED  sCtengel.  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania ;  Visiting  Physician  to  the 
Pennsylvania  Hospital.  Octavo,  873  pages,  nearly  400  illustrations  many 
of  thern  in  colors.     Cloth,  $5.00  net ;  Sheep  or  Half  Morocco,  ;g6.oo  net. 

STENGEL  AND  WHITE  ON  THE  BLOOD. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  ALFRED  Sten- 
gel. M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania  ;  and 
C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  Medicine,  University  of 
Pennsylvania.     In  Press. 

STEVENS'  MATERIA  MEDICA  AND  THERAPEUTICS.     Third 
Edition,  Entirely  Rewritten  and  Greatly  Enlarged. 

A  Text-Book  of  Modern  Therapeutics.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania. 

STEVENS'  PRACTICE  OF  MEDICINE.    Fifth  Edition,  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
IvCcturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania.  Spe- 
cially intended  for  students  preparing  for  graduation  and  hospital  examina- 
tions.    Post-octavo,  519  pages  ;  illustrated.     Flexible  Leather,  $2.00  net. 

STEWART'S  PHYSIOLOGY.    Fourth  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and  Prac- 
titioners. By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc,  Professor  of  Physiol- 
ogy in  the  Western  Resen-e  University,  Cleveland,  Ohio.  Octavo  volume 
of  894  pages  ;  336  illustrations  and  5  colored  plates.     Cloth,  J>3.75  net. 

STONEY'S  MATERIA  MEDICA  FOR  NURSES. 

Materia  Medica  for  Nurses.  By  Emilv  .A.  M.  Stoney,  late  Superintend- 
ent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston, 
Mass.     Handsome  octavo  volume  of  306  pages.     Cloth,  §1.50  net. 

STONEY'S  NURSING.    Second  Edition,  Revised. 

Practical  Points  in  Nunsing.  For  Nurses  in  Private  Practice.  By  EMILY 
A.  M.  Stoney,  late  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73  engravings  and 
8  colored  and  half-tone  plates.     Cloth,  $1.75  net. 

STONEY'S  SURGICAL  TECHNIC  FOR  NURSES. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  A.  M.  Stonev, 
late  Superintendent  of  the  Training-School  for  Nurses,  Carney  Hospital, 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.    Cloth,  $1.25  net. 


14  MEDICAL   PUBLICATIONS. 


THOMAS'S  DIET  LISTS.    Second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  JEROME  B.  THOMAS,  M.  D.,  In- 
structor in  Materia  Medica,  Long  Island  Hospital ;  Assistant  Bacteriologist 
to  the  Hoagland  Laboratory.     Cloth,  ^1.25  net.     Send  for  sample  sheet. 

THORNTON'S  DOSE-BOOK  AND  PRESCRIPTION-WRITINQ. 
Second  Edition,  Revised  and  Enlarged. 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  THORNTON, 
M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Philadel- 
phia.    Post-octavo,  362  pages,  illustrated.     Flexible  Leather,  $2.00  net. 

VECKI'S  SEXUAL  IMPOTENCE.    Third  Edition,  Revised. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  VICTOR  G.  Vecki, 
M.  D.  From  the  second  German  edition,  revised  and  enlarged.  Demi- 
octavo,  329  pages.     Cloth,  ^2.00  net. 

VIERORDT'S    MEDICAL   DIAGNOSIS.     Fourth    Edition,  Re- 
vised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth  en- 
larged German  edition,  with  the  author's  permission,  by  Francis  H. 
Stuart,  A.  M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194  wood- 
cuts, many  of  them  in  colors.  Cloth,  4.00  net;  Sheep  or  Half-Morocco, 
;5!5.oo  net. 

WATSON'S  HANDBOOK  FOR  NURSES. 

A  Handbook  for  Nurses.  By  J.  K.  WatsoN,  M.  D.  Edin.  American 
Edition,  under  supervision  of  \.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on 
Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages,  73  illus- 
trations.    Cldth,  IS1.50  net. 

WARREN'S  SURGICAL  PATHOLOGY.    Second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren,  M.  D., 
LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School. 
Handsome  octavo,  873  pages  ;  136  relief  and  lithographic  illustrations,  33  in 
colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis,  and  a 
series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net;  Sheep  or 
Half  Morocco,  $6.00  net. 

WARWICK  AND  TUNSTALL'S  FIRST  AID  TO  THE  INJURED 
AND  SICK. 

First  Aid  to  the  Injured  and  Sick.  By  F.J.  Warwick,  B.  A.,  M.  B. 
Cantab.,  M.  R.  C.  S.,  Surgeon-Captain,  Volunteer  Medical  Staff  Corps, 
London  Companies;  and  \.  C.  Tunstall,  M.  D.,  F.  R.C.  S.  Ed.,  Sur- 
geon-Captain commanding  East  London  Volunteer  Brigade  Bearer  Com- 
pany.    i6mo,  232  pages,  and  nearly  200  illustrations.     Cloth,  Ji.oo  net. 

WOLF'S  EXAMINATION  OF  URINE. 

A  Hand-Book  of  Physiologic  Chemistry  and  Urine  Examination.  By 
Charles  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry,  Cor- 
nell University  Medical  College.  i2mo  volume  of  204  pages,  47  illustra- 
tions.    Cloth,  $1.25  net. 


Saunders' 
Question=Compend    Series. 

Price,  Cloth,  $i.oo  net  per  copy,  except  when  otherwise  noted. 


"  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders 
Series,  in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 


1.  Essentials   of   Physiology.      By   Sidney   Budgett,   M.  D.    An  entirely  ne-w 

work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised, 

with  an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.   Nancrede,   M.  D.     Sixth   edition, 

thoroughly  revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.   By  Lawrence 

Wolff,  M.  D.     Fifth  edition,  revised. 

6.    Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.    Fourth  edition, 
revised  and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.    By  F.  J.  Kalteybr,  M.  D. 

/n  p  rfpa  ration . 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- Writing. 

Hy  Henky  Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.     Essentials  of  Practice  of  Medicine-     By  Henry  Morris,  M.  D.     An  Ap- 

pendix on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition, 
enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by 
Wm.  M.  Powell,  M.  D.     (Double  number,  I1.50  net.) 

10.  Essentials   of   Gynecology.     By   Edwin   B.  Cragin,  M.  D.        Fifth    edition, 

revised. 

11.  Essentials  of  Diseases  of  the  Skin.    By  Henry  W.  Stelwagon,  m.  D. 

Fourth  edition,  revised  and  enlarged. 

12.  Essentials  Of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Edward  M.-^rtin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials  of  Legal  Medicine,  Toxicology,  and  Hygiene.    This  volume  is 

at  present  out  of  print. 

14.  Essentials  of  Diseases   of  the  Eye.     By   Edward  Jackson,   M.  D.    Third 

edition,  revised  and  enlarged. 

18.    Essentials  of  Diseases  of  Children.     By  William  M.  Powell,  M.  D.    Third 

16.  Essentials  of  Examination  of  Urine.     By  Lawrence  Wolff,  M.  D.     Colored 

"  VoGEL  Sc.\LE."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.    By  S.  Solis-Cohen,  m.  d.,  and  A.  A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials  of  Practice  of  Pharmacy.    By  Lucms  E.  Sayre.    Second  edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat.    By  E.  B.  Glbason,  m.  d 

Third  edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  V.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  Of  Nervous  Diseases  and  Insanity.    By  John  C.  Shaw,  M.  D. 

Third  edition,  revised. 

22.  Essentials  of  Medical  Physics.     By  Fred  J.  Brockway,  M.  D.     Second  edi- 

tion, revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and   Ed- 

ward S.  Lawkance,  NL  D. 

24.  Essentials  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  M.  D.    Second  edition, 

revised  and  greatly  enlarged. 
26.    Essentials  of  Histology.    By  Louis  Leroy,  M.  D.    With  73  original  Ulustrationt. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 

15 


Saunders'  Medical  Iiand=AtIases. 


volume:s  now  ready. 

atlas  and  epitome  of  internal  medicine  and 
clinical  diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  179 
colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth, 
^3.00  net. 

ATLAS  OF  LEGAL  MEDICINE. 

By  Dr.  E.  R.  von  Hoff.man,  of  Vienna.  Edited  by  Frederick  Peter- 
son, M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of  Physicians  and 
Surgeons,  New  York.  With  120  colored  figures  on  56  plates  and  193  beau- 
tiful half-tone  illustrations.     Cloth,  $3.50  net. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  THE  LARYNX. 

By  Dr.  L.  Grunwald,  of  .Munich.  Edited  by  CHARLES  P.  GRAYSON, 
M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the 
University  of  Pennsylvania.  With  107  colored  figures  on  44  plates,  25  text- 
illustrations,  and  103  pages  of  text.     Cloth,  ^2.50  net. 

ATLAS  AND  EPITOME  OF  OPERATIVE  SURGERY. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited  by  J.  Chalmers  DaCosta, 
M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.  With  24  colored  plates,  214  text-illustra- 
tions, and  395  pages  of  text.     Cloth,  $3.00  net. 

ATLAS  AND  EPITOME  OF  SYPHILIS  AND  THE  VENEREAL 
DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs, 
M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  With  71  colored  plates,  16  illustrations, 
and  122  pages  of  text.     Cloth,  $3.50  net. 

ATLAS  AND  EPITOME  OF  EXTERNAL  DISEASES  OF  THE 
EYE. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  DE  SCHWEINITZ,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With 
76  colored  illustrations  on  40  plates  and  228  pages  of  text.     Cloth,  ^3.00  net. 

ATLAS  AND  EPITOME  OF  SKIN  DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON.  M.D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical  Col- 
lege, Philadelphia.  With  63  colored  plates,  39  half-tone  illustrations,  and 
200  pages  of  text.     Cloth,  ^3. 50  net. 

ATLAS  AND   EPITOME  OF  SPECIAL  PATHOLOGICAL  HIS- 
TOLOGY. 

By  Dr.  H.  DOrck,  of  Munich.  Edited  by  Lidvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tract, 
120  colored  figures  on  62  plates,  158  pages  of  text.  Part  11.,  including 
Liver,  Urinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones.  123  colored  figures  on  60  plates,  192  pages  of  text.  Per 
volume  :  Cloth,  ^$3.00  net. 

16 


Saunders*  Medical  Hand=Atlases. 


VOLUMES  JUST  ISSUED. 

ATLAS  AND  EPITOME  OF  DISEASES  CAUSED  BY  ACCI- 
DENTS. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Edited  with  additions  by  Pearce 
Bailey,  M.  D.,  Attending  Physician  to  the  Department  of  Corrections  and 
to  the  Almshouse  and  Incurable  Hospitals,  New  York.  With  40  colored 
plates,  143  text-illustrations,  and  600  pages  of  text.     Cloth,  ;^.oo  net. 

ATLAS  AND  EPITOME  OF  GYNECOLOGY. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited  by  RICHARD  C.  N'ORRIS,  A.  M.,  M.D.,  Gynecologist  to 
the  Methodist  Episcopal  and  the  Philadelphia  Hospitals;  Surgeon-in-Charge 
of  Preston  Retreat,  Philadelphia.  With  90  colored  plates,  65  text-illustra- 
tions, and  308  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS   AND   EPITOME  OF  THE  NERVOUS  SYSTEM  AND 
ITS  DISEASES. 

By  Proff^sor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Revised 
and  Enlarged  German  Edition.  Edited  by  Edward  D.  Fisher,  M.  D., 
Professor  of  Diseases  of  the  Nervous  System.  University  and  Bellevue  Hos- 
pital .Medical  College,  N.  Y.     With  83  plates;  copious  text.    $3.50  net, 

ATLAS  AND   EPITOME  OF  LABOR    AND  OPERATIVE    OB- 
STETRICS. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and  Enlarged 
German  Edition.  Edited  by  J.  CLIFTON  Edgar,  M.  D.,  Professor  of  Ob- 
stetrics and  Clinical  Midwifery,  Cornell  University  Medical  School.  With 
126  colored  illustrations.     ;5S2.oo  net. 

ATLAS  AND  EPITOME  OF  OBSTETRICAL  DIAGNOSIS  AND 
TREATMENT. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Second  Revised  and  En- 
larged German  Edition.  Edited  by  J.  CLIFTON  EDGAR,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School. 
72  colored  plates,  numerous  text-illustrations,  and  copious  text.     $3.00  net. 

ATLAS  AND  EPITOME  OF  OPHTHALMOSCOPY   AND  OPH- 
THALMOSCOPIC DIAGNOSIS. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged  Ger- 
man Edition.  Edited  by  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Oph- 
thalmology, Jefferson  Medical  College,  Philadelphia.  With  152  colored 
figures  and  82  pages  of  text.     Cloth,  $3.00  net. 

ATLAS  AND  EPITOME  OF  BACTERIOLOGY. 

Including  a  Hand-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof.  Dr. 
K.  B.  Lehman.n  and  DR.  R.  O.  Neumann,  of  Wurzburg.  From  the  Second 
Revised  German  Edition.  Edited  by  GEORGE  H.  Weaver.  W.  D.,  Assistant 
Professor  of  Pathology  and  Bacteriology,  Rush  Medical  College.  In  Two 
Parts.  Part  I.,  consisting  of  632  colored  figures  on  69  plates.  Part  II., 
consisting  of  511  pages  of  text,  illustrated.     Per  Part:  Cloth,  ^.-p  net. 

ADDITIONAL  VOLUMES  IN  PREPA RATION. 

»7 


NothnagePs  Encyclopedia 

OF 

PRACTICAL    MEDICINE. 

AMERICAN  EDITION. 
Edited  by  ALFRED  STENGEL,  M.  D., 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Pliysician  to  the  Pennsylvania  Hospital. 

¥T  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal  Medicine; 

■  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Specielle  Pathologie  und 
Therapie  "  is  conceded  by  scholars  to  be  without  question  the  best  System  of  Medicine 
in  existence.  So  necessary  is  this  book  in  the  study  of  Internal  Medicine  that  it  comes 
largely  to  this  country  in  the  original  German.  In  view  of  these  facts,  Messrs.  W.  B. 
Saunders  &  Company  have  arranged  with  the  publishers  to  issue  at  once  an  authorized 
American  edition  of  this  great  encyclopedia  of  medicine. 

For  the  present  a  set  of  ten  volumes,  representing  the  most  practical  part  of  this 
excellent  encyclopedia,  and  selected  with  especial  thought  of  the  needs  of  the  practical 
physician,  will  be  published.  These  volumes  will  contain  the  real  essence  of  the  entire 
work,  and  the  purchaser  will  therefore  obtain  at  less  than  half  the  cost  the  cream  of  the  origi- 
nal.    Later  the  special  and  more  strictly  scientific  volumes  will  be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist  on  the  subject  to 
which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to  date,  and  the  American  edition 
will  be  more  than  a  mere  translation  of  the  German  ;  for,  in  addition  to  the  matter  contained 
in  the  original,  it  will  represent  the  very  latest  views  of  the  leading  American  and 
English  specialists  in  the  various  departments  of  Internal  Medicine.  The  whole  System 
will  be  under  the  editorial  supervision  of  Dr.  Alfred  Stengel,  who  will  select  the  subject; 
for  the  American  edition,  and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended  over  a 
number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming  year,  and  the 
remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume  will  be  revised  to  the 
date  of  its  publication  by  the  eminent  editor.  This  will  obviate  the  objection  that  has 
heretofore  existed  to  systems  published  in  a  number  of  volumes,  since  the  subscriber  will 
receive  the  completed  work  while  the  earlier  volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been  to  compel 
physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases  to  be  undesirable. 
Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be  given  the  opportunity  of 
subscribing  for  the  entire  System  at  one  time;  but  any  single  volume  or  any  number  of 
volumes  may  be  obtained  by  those  who  do  not  desire  the  complete  series.  This  latter 
method,  while  not  so  profitable  to  the  publishers,  offers  to  the  purchaser  many  advan- 
tages which  will  be  appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire  work 
at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question,  form  the 
greatest  System  of  Medicine  ever  produced,  and  the  publishers  are  confident  that  it 
will  meet  with  general  favor  in  the  medical  profession, 

l8 


NOTHNAGEL'S  ENCYCLOPEDIA. 

AMERICAN  EDITION. 
VOLUMES  JUST  ISSUED  AND  IN  PRESS. 

TYPHOID  AND  TYPHUS  FEVERS.     By  Dr.  H.  Curschmann,  of  Leipsic. 

Editor,  William  Osier,  M.D.,  F.R.C.P.,  Professor  of  the  Principles  and  Practice 
of  Medicine  in  Johns  Hopkins  University,  Bahimore.  Handsome  octavo,  646  pages, 
72  valuable  text  illustrations,  and  two  lithographic  plates.  Cloth,  $5.00  net;  Half 
Morocco,  ^.00  net.    Just  Ready. 

VARIOLA  (including  VACCINATION).  By  Dk.  H.  Immermann,  of  Basle. 
VARICELLA.  By  Dr.  Th.  von  Jurgensen,  of  Tiibingen.  CHOLERA 
ASIATICA  and  CHOLERA  NOSTRAS.  By  Dr.  C.  Liebermeister,  of 
Tubingen.  ERYSIPELAS  and  ERYSIPELOID.  By  Dr.  H.  Lenhaktz,  of 
Hamburg.  PERTUSSIS  and  HAY-FEVER.  By  Dr.  G.  Sticker,  of  Giessen. 
Editor.  Sir  J.  W.  Moore,  B.A.,  M.D.,  F.R.C.P.I.,  Professor  of  the  Practice  of 
Medicine,  Royal  College  of  Surgeons,  Ireland.  Handsome  octavo  of  682  pages,  illus- 
trated.    Cloth,  $5.00  net  ;   Half  Morocco,  g6.oo  net.    Just  Ready. 

DIPHTHERIA.  By  the  editor.  Measles,  Scarlet  Fever,  RStheln.  By  Dr.  Th.  von 
Jurgensen,  of  Tubingen.     In  Press. 

Editor,  William  P.  Northrup,  M.D.,  Professor  of  Pediatrics,  University  and  Belle- 
vue  Medical  College,  New  York.    Handsome  octavo,  800  pages,  illustrated.     In  Press. 

DISEASES  OF  THE  BRONCHI.  By  Dr.  F.  A.  Hoffmann,  of  Leipsic.  DIS- 
EASES OF  THE  PLEURA.  By  Dr.  O.  Rosenbach,  of  Berlin.  PNEU- 
MONIA.    By  Dr.  E.  Aufrecht,  of  Magdeburg. 

Editor,  John  H.  Musser,  M.D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania.    Handsome  octavo,  800  pages,  7  full-page  lithographs  in  colors.     In  Press. 

INFLUENZA  AND  DENGUE.  By  Dr.  O.  Lkichtenstern,  of  Cologne.  MALA- 
RIAL DISEASES.     By  Dr.  J.  Mannaberg,  of  Vienna. 

Editor,  Ronald  Ross,  F.R.C.S.,  Eng.,  D.P.H.,  F.R.S.,  Major,  Indian  Medical 
Service,  retired;  Walter  Myers  Lecturer,  Liverpool  School  of  Tropical  Medicine. 
Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors. 

ANEMIA,  LEUKEMIA,  PSEUDOLEUKEMIA,  HEMOGLOBINEMIA.  By 
Dr.  P.  Ehklich,  of  Frankfort-on-the-Main,  Dr.  A.  Lazarus,  of  Charlottenburg,  and 
Dr.  Felix  Pinkus,  of  Berlin.  CHLOROSIS.  By  Dr.  K.  von  Noorden,  of 
Frankfort-on-the-Main. 

Editor,  Alfred  Stengel,  M.D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania.    Handsome  octavo,  750  pages,  5  full-page  lithographs  in  colors. 

TUBERCULOSIS  AND  ACUTE  GENERAL  MILIARY  TUBERCULOSIS. 

By  Dr.  G.  Cornet,  of  Berlin. 

Editor  to  be  announced  later.     Handsome  octavo,  700  pages. 

DISEASES  OF  THE  STOMACH.     By  Dr.  F.  Riegel,  of  Giessen. 

Editor,  Charles  G.  Stockton,  M.D.,  Professor  of  Medicine,  University  of  Buflfalo. 
Handsome  octavo,  800  pages,  with  29  text-cuts  and  6  full-page  plates. 

DISEASES  OF  THE  LIVER.  By  Drs.  H.  Quincke  and  G.  Hoppe-Seyler,  of 
Kiel.  DISEASES  OF  THE  PANCREAS.  By  Dr.  L.  Oser,  of  Vienna.  DIS- 
EASES OF  THE  SUPRARENALS.  By  Dr.  E.  Neusser,  of  Vienna. 
Editors,  Frederick  A.  Packard,  M.D.,  Physician  to  the  Pennsylvania  and  to  the 
Children's  Hospitals,  Philadelphia  ;  and  Reginald  H.  FitZ,  A.M.,  M.D.,  Hersey 
Professor  of  the  Theory  and  Practice  of  Physic,  Harvard  University. 

DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.  By  Dr.  Hermann 
Nothnagel,  of  Vienna. 

Editor,  Htimphry  D.  RoUeston,  M.D.,  F.R.C.P.,  Physician  to  and  Lecturer  on 
Pathology  at  St.  George's  Hospital,  London.  Handsome  octavo,  800  pages,  finely 
illustrated. 

19 


CLASSIFIED    LIST 

OF   THB 

MEDICAL    PUBLICATIONS 

OH 

W.  B.  Saunders  &  Company. 


ANATOMY.  EMBRYOLOGY,  HIS- 
TOLOGY. 

Bohm,  Davidoff,  and  Huber— A  Text- 
Book  of  Histology, 4 

Clarkson — A  Text-Book  of  Histology,   .  s 

Haynes — A  Manual  of  Anatomy,   ...  7 

Heisler— A  Text-Book  of  Embryology,  .  8 

Leroy — Essentials  of  Histology 15 

McClellan — Anatomy    in    Relation    to 

Art ;   R-egional  Anatomy, 10 

Nancrede — Essentials  of  Anatomy,  ...  15 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  ....  10 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology 15 

Frothingham — Laboratory  Guide,  ...  6 

Gorham — Laboratory  Bacteriology,   .    .  7 
Lehmann    and     Neumann— Atlas    of 

Bacteriology 17 

Levy  and  Klemperer's  Clinical  Bacte- 
riology,      9 

Mallory    and     Wright— Pathological 

Technique, 9 

McFarland — Pathogenic  Bacteria,  ...  10 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart,      ...  7 

Hart — Diet  in  Sickness  and  in  Health,    .  7 

Keen — Operation  Blank, 9 

Laine — lemperature  Chart, 9 

Meigs — Feeding  in  Early  Infancy,    ...  10 

Starr — Diets  for  Infants  and  Children,  .  13 

Thomas — Diet-Lists, 14 

CHEMISTRY  AND  PHYSICS. 

Brockway — Ess.  of  Medical  Physics,  .  15 

Telliflfe  and  Diekman — Chemistry,   .   .  22 

'wolf — Examination  of  Urine, 14 

Wolff — Essentials  of  Medical  Chemistry,  15 

CHILDREN. 
An  American  Text-Book  of  Diseases 

of  Children, 1 

Griffith — Care  of  the  Baby, 7 

Griffith — Infant's  Weight  Chart,  ....  7 

Meigs — P'eeding  in  Early  Infancy,  ...  10 

Po^vcll — Essentials  of  Dis.  of  Children,  15 

Starr — Diets  for  Infants  and  Children,   .  13 


EYE,  EAR,  NOSE,  AND  THROAT. 
An  American  Text-Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,  .    .  i 
Bruhl  and  Politzer^Atlas  of  Ear,   .   .  22 
De  Schweinitz — Diseases  of  the  Eye,   .  6 
Friedrich  and  Curtis — Rhinology,  Lar- 
yngology, and  Otology, 6 

Gleason — Essentials  of  the  Ear,    ....  15 
Gleason — Essentials  of  Nose  and  Throat,  15 
Gradle — Ear,  Nose, and  Throat,  .    .        .7 
Grunwald  and  Grayson — Atlas  of  Dis- 
eases of  the  Larynx, x6 

Haab  and  de  Schweinitz— Atlas  of  Ex- 
ternal Diseases  of  the  Eye, 16 

Jackson — .Manual  of  Diseases  of  the  Eye,  8 

Jackson — Essentials  Diseases  of  Eye,    .  15 

Kyle — Diseases  of  the  Nose  and  Throat,  9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 3 

Hyde  and  Montgomery — Syphilis  and 

the  Venereal  Diseases, 8 

Martin — Essentials   of    Minor   Surgery, 

Bandaging,  and  Venereal  Diseases,  .    .  15 

Mracek  and   Bangs — Atlas  of  Syphilis 

and  the  Venereal  Diseases, 16 

Saundby — Renal  and  Urinary  Diseases,  ix 

Senn— Genito-Urinary  Tuberculosis,   .   .  xa 

Vecki — Sexual  Impotence, 14 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,  .  a 

Cragin — -Essentials  of  Gynecology,  ...  15 

Garrigues — Diseases  of  Women,  ....  7 

Long — Syllabus  of  Gynecology,   ....  tf 

Penrose — Diseases  of  Women, ii 

SchaefTer  and  Norris — Atlas  of  Gyne. 

cology, 17 

HYGIENE. 
Abbott — Hygiene  of  Transmissible  Dis- 
eases,      3 

Bergey — Principles  of  Hygiene 4 

Pyle — Personal  Hygiene, 11 


DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Diag- 


Cor\vin — Physical  Diagnosis, 
Vierordt — Nledical  Diagnosis, 


DICTIONARIES. 

The  American  Illustrated  Medical 
Dictionary,     . 

The  American  Pocket  Medical  Dic- 
tionary,     

Morton — Nurses'  Dictionary, 


MATERIA      MEDICA,      PHARMA- 
!     COLOGY.  and  THERAPEUTICS. 
I  An  American   Text-Book  of  Applied 

'5  I      Therapeutics, i 

5    Butler — Text-Book   of  Materia  Medica, 

'4  I      Therapeutics,  and  Pharmacology,    .    .      5 

Morris — Ess.of  M.  M.  and  Therapeutics,    15 

Saunders'  Pocket  Medical  Formulary,  .    12 

Sayre — Essentials  of  Pharmacy,  ....    15 

3    Sollmann — Text-Book  of  Pharmacology,  12 

Stevens — Modern  Therapeutics,      ...    13 

3     Stoney— Materia  Medica  for  Nurses,  .    .    13 

10  i  Thornton — Prescription-Writing,     ...    14 

20 


MEDICAL  PUBLICATIONS 


21 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicology S 

Crothers — Morphinism 'z-z 

Golebiewski  and  Bailey— Atlas  of  JJis- 
eases  Caused  by  Accidents, 17 

Hofmannand  Peterson— Atlas  of  Legal 
Medicine,        ■  ...   16 

NERVOUS  AND  MENTAL  DIS- 
EASES, ETC. 

Brower — Manual  of  Insanity 4 

Chapin — Compendium  of  Insanity,  ...     5 
Church   and    Peterson — Nervous  and     5 

Mental  Diseases 5 

Jakob  and   Fisher — Atlas   of    Nervous 

System 17 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 15 


NURSING. 
Davis — Obstetric  and  Gynecologic  Nurs 

ing, 

Griffith— The  Care  of  the  Baby,  .  . 
Hart — Diet  in  Sickness  and  in  Health, 
Meigs — Feeding  in  Early  Infancy,  . 
Morten — Nurses'  Dictionary,  .  .  . 
Stoney — Materia  Medica  for  Nurses, 
Stoney — Practical  Points  in  Nursing, 
Stoney — Surgical  Technic  for  Nurses, 
Watson — Handbook  for  Nurses,  .   .    . 


17 


OBSTETRICS. 

An  American  Text-Book  of  Obstetrics, 
Ashton — Essentials  of  Obstetrics,  . 
Boisliniere— Obstetric  Accidents, 
Dorland— Modern  Obstetrics,  .     . 
Hirst— Text-Book  of  Obstetrics,   . 
Norris — Syllabus  of  Obstetrics,  .   .    .    . 
SchaefTer  and  Edgar— Atlas  of  Obstet 
rical  Diagnosis  and  Treatment, 

PATHOLOGY. 

An  American  Text-Book  of  Pathology,  2 

Durck— Atlas  of  Pathologic  Histology,  16 

Kalteyer — Essentials  of  Pathology,   .   .  22 
Mallory    and    Wright— Pathological 

Technique, 9 

Senn — Pathology,  and    Surgical    Treat- 
ment of  Tumors, 12 

Stengel— Text-Book  of  Pathology,  ...  13 

Warren — Surgical  Pathology,   ....  14 

PHYSIOLOGY. 

American  Text-Book  of  Physiology.  .  a 

Raymond — Text- Book  of  Physiology,  .  11 

Stewart — Manual  of  Physiology,  ...  13 

PRACTICE  OF  MEDICINE. 
An  American  Year-Book  of  Medicini 

and  Surgery, 3 

Anders— Practice  of  Medicine, 4 

Eichhorst  — Practice  of  Medicine,  .    .    .  6 

Lockwood — Practice  of  Medicine,  .    .    .  9 

Morris — Ess.  of  Practice  of  Medicine,  .  15 

Nothnagel's  Encyclopedia '8,  19 

Salinger&  Kalteyer — Mod.  Medicine,  11 

Stevens  — Practice  of  Medicine,    ...  13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, a 

Hyde  and  Montgomery — Syphilis  and 

the  Venereal  Diseases, 8 

Martin— Essentials   of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  .    .  15 

Mracek  and  Stelwagon— Atlas  of  Dis- 
eases of  the  Skin, 16 

Stelwagon— Diseases  of  the  Skin,  ...  22 

Stelwagon — Ess.  of  Diseases  of  Skin,  .  15 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  2 
An  Atnerican  Year-Book  of  Medicine 

and  Surgery, 3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis      .    .  4 

Da  Costa — Manual  of  Surgery,    ....  5 

Helferich — Atlas  of  FVactures 22 

International  Text-Book  of  Surgery,  8 

Keen — Operation   Blank, 9 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever 8 

Macdonald  —  Surgical     Diagnosis    and 

Treatment, 9 

Martin — p^ssentials  of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  .    .  15 

Martin — Essentials  of  Surgery, 15 

Moore — Orthopedic  Surgery, 10 

Nancrede — Principles  of  Surgery,  ...  10 

Pye— Bandaging  and  Surgical  Dressing,  n 

Scudder — Treatment  of  Fractures,  ...  12 

Senn— Genito-Urinary  Tuberculosis,  .    .  12 

Senn— Practical  Surgery, 12 

Senn — Syllabus  of  Surgery, la 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 12 

Sultan — Atlas  of  Abdominal  Hernia,  .    .  22 
Warren — Surgical  Pathology  and  Ther- 
apeutics,    14 

Zuckerkandl  and  Da  Costa— Atlas  of 

Operative  Surgery 16 

URINE  AND  URINARY  DISEASES. 
Ogden — Clinical     Examination    of    the 

Urine, n 

Saundby — Renal  and  Urinary  Diseases,  11 

Wolf — Handbook  of  Urine  Examination,  14 

Wolff — Examination  of  Urine, 15 

MISCELLANEOUS. 

Abbott — Hygiene  of  Transmissible  Dis- 
eases,     3 

Bastin — Laboratory  Exercises  in  Bot- 
any,    4 

Golebiewski  and  Bailey— Atlas  of  Dis- 
eases Caused  by  Accidents,  .       .       .    .  17 
Gould  and   Pyle — Anomalies  and  Curi- 
osities of  Medicine, 7 

Grafstrom— Massage, 7 

Keating— Examination  for  Life  Insur- 
ance   8 

Pyle  — A  Manual  of  Personal  Hygiene,  .  11 

Saunders'  Medical  Hand-Atlases,  .     i6,  17 

Saunders'  Pocket  Medical  Formulary.  .  12 

Saunders'  Question-Compends,   .    .     14.  15 
Stewart  and  Lawrence— Essentials  of 

Medical   Electricity, 15 

Galbraith- The  Four  Epochs  of  Wo- 
man's Life 6 


BOOKS  IN  PREPARATION. 


JELLIFFE  AND  DIEKMAN'S  CHEMISTRY. 

A  Text-Book  of  Chemistry.  By  Smith  Ely  Jf.lliffe,  M.  D.,  Ph.  D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York ;  and 
George  C.  Diekman,  Ph.G.,  M.  D.,  Professor  of  Theoretical  and  Ap- 
plied Pharmacy,  College  of  Pharmacy,  New  York.  Octavo,  550  pages, 
illustrated.     Ready  Shortly. 

STELW AGON'S  DISEASES  OF  THE  SKIN. 

Diseases  of  the  Skin.  By  Henry  W.  Stelwagon,  M.  D.,  Clinical  Pro- 
fessor of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  Royal 
octavo,  800  pages,  fully  illustrated.     Ready  Shortly. 

KALTEYER'S  PATHOLOGY. 

Essentials  of  Pathology.  By  F.  J.  Kalteyer,  M.  D.,  Assistant  in 
Clinical  Medicine,  Jefferson  Medical  College  ;  Pathologist  to  the  Lying- 
in  Charity  Hospital,  etc.  In  Saunders'  Question- Compend  Series.  Ready 
Shortly. 

CROTHER'S  MORPHINISM  AND  NARCOMANIA. 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs,  including  the  Etiology,  Treat- 
ment, and  Medicolegal  Relations.  By  T.  D.  Crothers,  M.  D.,  Super- 
intendent of  Walnut  Lodge  Hospital,  Hartford,  Conn. ;  Professor  of 
Mental  and  Nervous  Diseases,  New  York  School  of  Clinical  Medicine, 
etc.     l2mo,  250  pages.     Ready  Shortly. 

BRUHL  AND  POLITZER'S  ATLAS  OF  EAR. 

Atlas  and  Epitome  of  Diseases  of  the  Ear.  By  Dr.  Gustav  BrUhl, 
of  Berlin,  with  the  collaboration  of  Pkof.  Dr.  A.  Politzer,  of  Vienna. 
Edited,  with  additions,  by  S.  MacCuen  Smith,  M.  D.,  Clinical  Professor 
of  Otology,  Jefferson  Medical  College,  Phila.  239  colored  figures  on  39 
plates,  205  text-cuts,  and  about  275  pages  of  text.  In  Saunders'  Hand- 
Atlas  Series.     Ready  Shortly. 

SULTAN'S  ATLAS  OF  ABDOMINAL  HERNIA. 

Atlas  and  Epitome  of  Abdominal  Hernia.  By  Privatdocent  Dr. 
Georg  .Sultan,  of  Gottingen.  Edited,  with  additions,  by  William 
B.  CoLEY,  Clinical  Lecturer  on  Surgery,  College  of  Physicians  and  Sur- 
geons, New  York.  With  43  colored  figures  on  36  plates,  100  text-cuts, 
and  about  250  pages  of  text.     In  Saunders'  Hand-Atlas  Series. 

HELFERICH'S  ATLAS  OF  FRACTURES. 

Atlas  and  Epitome  of  Fractures  and  Luxations.  By  Prof.  Dr.  H. 
Helfb:rich,  of  Kiel.  Edited,  with  additions,  by  Joseph  C.  Blood- 
good,  Associate  in  Surgery,  Johns  Hopkins  University,  Baltimore. 
With  215  colored  figures  on  72  plates,  144  text-cuts,  42  skiagraphs, 
and  over  300  pages  of  text.     In  Saunderi  Hand-Atlas  Series. 

22 


3X 


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305  De  Neve  Drive  -  Parking  Lot  17  •  Box  951388 

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Return  this  material  to  the  library  from  wiiich  It  was  borrowed. 


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